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http://www.archive.org/details/tuberculosistreOOkleb 


TUBERCULOSIS 


TUBERCULOSIS 


A   TREATISE    BY   AMERICAN    AUTHORS 

aV  ITS   ETIOLOGY,   PATHOLOGY,   FREQUENCY 

SEMEIOLOGY,    DIAGNOSIS,    PROGNOSIS 

PREVENTION,  AND  TREATMENT 


EDITED   BY 

ARNOLD    C.   KLEES,  M.D. 


WITH  THREE  COLORED  PLATES  AND 
TWO  HUNDRED  AND  FORTY-THREE  ILLUSTRATIONS  IN  TEXT 


NEW    YORK    AND    LONDON 

D.     APPLETON     AND     COMPANY 

1909 


Copyright,  1909,  by 
D.    APPLETON    AND    COMPANY 


)0- 


PRINTED   AT   THK   APPLKTON   PRESS 
NEW    YORK,    U.    S.    A. 


EDITOK'S   PREFACE 


A  CONTINUOUS  and  systematic  discussion  of  the  whole  subject  of 
tuberculosis  in  all  those  phases  of  interest  and  value  to  the  practitioner 
by  a  single  author  has  become  an  impossibility.  In  view  of  the  enor- 
mous literature — nearly  three  tliousand  pul)lications  of  1908  alone  have 
been  collected  in  the  editor's  office — the  task  of  sifting  the  important 
from  the  unimportant  can  only  be  undertaken  by  those  who  can  devote 
much  time  exclusively  to  one  distinct  phase.  The  study  of  tuberculosis 
thus  necessitates  a  specialization  within  the  range  of  a  special  subject. 

Every  chapter  in  this  book  deals  with  a  distinct  phase  of  the  subject, 
and  is  treated  by  authors  whose  particular  familiarity  with  it  is  well 
recognized — in  several  instances  even  far  beyond  the  boundaries  of  this 
country.  It  has  been  the  endeavor  of  the  editor  to  bring  the  articles 
into  proper  juxtaposition  by  personal  intercourse  and  extensive  corre- 
spondence with  the  contributors,  so  that  the  principal  theme  is  treated 
in  a  uniform  manner,  and  does  not  merely  represent  a  collection  of 
articles,  but  a  consistent  whole  to  fill  the  requirements  of  the  man  in 
busy  practice  and  without  the*  "  cold  neutrality "  of  a  mere  work  of 
reference.  Altliough  the  fullest  attention  has  been  paid  to  the  funda- 
mental work  done  in  other  countries,  it  is  but  natural  that  in  this  Ameri- 
can treatise  a  full  consideration  is  given  to  the  work  done  here,  the 
value  of  which  will  undoubtedly  become  more  and  more  generally  ap- 
preciated. Thus  it  may  be  hoped  that  the  international  cooperation 
auspiciously  inaugurated  at  the  Washington  Congress  may  also  be  fur- 
thered by  this  work  for  the  benefit  of  all  concerned. 

The  guiding  consideration  of  the  needs  of  the  practitioner  has  neces- 
sitated a  shorter  discussion  of  certain  subjects  which  have  received  con- 
siderable space  in  other  works.  An  often  bewildering  completeness  has 
thereby  been  avoided.  A  carefully  selected  bibliography,  however,  ar- 
ranged by  names  of  authors  and  subjects  as  well,  should  prove  of  assist- 


vi  EDITOR'S   PREFACE 

ance  to  those  who  wish  to  inform  themselves  about  special  questions  not 
extensively  discussed  in  the  text.  But  it  may  be  confidently  asserted 
that  the  practitioner  will  find  in  the  following  pages  a  lucid  discussion 
of  the  great  problem  of  tuberculosis,  based  upon  the  most  recent  con- 
ceptions of  the  international  army  of  busy  workers,  sufficiently  full  to 
aid  him  in  the  solution  of  the  ever-recurring  puzzles  which  this  disease 
presents  to  him  as  a  physician  and  citizen  as  well. 

The  admirable  X-ray  plates  we^e  kindly  furnished  by  Dr.  Lewis 
Gregory  Cole,  of  New  York.  They  are  remarkable  for  their  clearness 
and  jDcrfection  of  detail.  It  must  be  borne  in  mind,  however,  that  these 
were  taken  with  the  patient  recumbent,  which  accounts  for  the  oblique 
position  of  the  clavicles  and  certain  other  minor  differences  from  the  pic- 
ture as  seen  on  the  fluoroscope,  which  is  usually  used  with  the  patient 
erect  and  with  the  clavicles  therefore  more  nearly  horizontal. 

Arnold  C.  Klebs. 


CONTKIBUTORS 


Edward  R.  Baldwin,  Saranac,  jST.  Y. 

Resistance,  Predisposition,  and  Immunity. 
Individual  Prophylaxis. 

Jaevis  Barlow,  Los  Angeles,  Cal. 
Clim atic  Th crape u tics. 

Hermaxn  M.  Biggs,  New  York  City. 
Intruduction  to  Prophylaxis. 

Lawrason  Brown,  Saranac^.  K.  Y. 
Specific  Treatment. 

Thomas  D.  Coleman,  Augusta,  Ga. 

Tuberculosis  Among  the  Dark-shinned  Paces  of  America. 
Home  Treatment  by  Sanatorium  Methods. 

Leonard  Freeman,  Denver,  Col. 

Tuberculosis  of  the  Lymph  Glands. 
Primary  Tuberculosis  of  Muscles  and  Fascice. 
Tuberculous  Ischiorectal  Abscess  and  Aual  Fistula. 
Tuberculosis  of  the  Gcnito-Urinary  System. 

LuDwiG  Hektoen,  Chicago,  111. 

Tubercle  and  Morbid  Anatomy. 

Eichard  H.  Hutchings,  Ogdensburg,  N.  Y. 

Frequency  of  Tuberculosis  in  Insane  Asylums. 

Arxold  C.  Klebs,  Chicago,  111. 
Frequency  of  Tuberculosis. 
The  Sanatorium,  its  Construction  and  Management. 


VlU  CONTRIBUTORS 

S.  Adolphus  Knopf,  Nbav  York  City. 

Public  Measures  in  the  Prophylaxis  of  Tuberculosis. 

L.  L.  McArthur,  Chicago,  111. 

Tuberculosis  of  Bones  and  Joints. 
Tuberculosis  of  the  Brain  and  its  Membranes. 
Intestinal  Tuberculosis. 
Tuberculosis  of  the  Peritoneum. 

Charles  L.  Minor,  Asheville,  N.  C. 

Symptomatology  of  Pulmonary  Tuberculosis. 

Physical  Examination. 

Diagnosis. 

William  Osler,  Oxford,  England. 
Historical  Introduction. 

Clemons  von  Pirquet,  Baltimore,  Md. 

Tuberculosis  in  Childhood. 

Mazyck  p.  Pavenel,  Madison,  Wis. 
Etiology — The  Tubercle  Bacillus. 

Henry  Sewall,  Denver,  Col. 
The  Physiology  of  Climate. 

Edward  L.  Trudeau,  Saranae,  N.  Y. 
Introduclion  to  Treatment. 

Gerald  B.  Webb,  Colorado  Springs,  Col. 

Specific  Therapeutics  of  Mixed  and  Concomitant  Infections. 


CONTENTS 


INTRODUCTION 

PAGE 

Historical  Sketch 3 

Semeiological 3 

Anatomical 5 

Etiological 5 

Prevention 7 

American  Work  on  Tuberculosis g 

PART   I 

ETIOLOGY  AND  MORBID  ANATOMY 

CHAPTER  I 

ETIOLOGY— THE   TUBERCLE    BACILLUS 

History 13 

Types  of  Tubercle  Bacillus 13 

Morphology  of  the  Tubercle  Bacillus 15 

Staining 15 

Other  Acid-fast  Bacilli — Pseudo-Tubercle  Bacilli 19 

Diagnosis  of  Tuberculosis  by  Microscopic  Examination 20 

Cultivation  of  the  Tubercle  Bacillus 20 

Biology  of  Tubercle  Bacillus     .        .  * 23 

Chemical  Composition  of  the  Tubercle  Bacillus 26 

Poisons  of  the  Tubercle  Bacillus 2S 

Preparation  of  Tuberculin *  30 

Modes  of  Invasion 33 

Addenda 46 


CHAPTER   II 
TUBERCLE    AND    MORBID   ANATOMY 

Histogenesis  and  Fate        .... 

Origin  of  Tubercle       .... 

Tuberculous  Granulation  Tissue 

Tuberculous  Exudative  Inflammation 

Caseation 

Healing 

Points  of  Entrance  and  Primary  Localization  of  Tubercle  Bacilli 
Dissemination  of  Tuberculosis  within  the  Infected  Body 


52 
52 
55 
56 
56 
5!t 
(50 
62 


X  CONTENTS 

Acute  General  Miliary  Tuberculosis 

The  Morbid  Anatomy  of  Pulmonary  Tuberculosis       .... 
Acute  General  Hematogenous  Tuberculosis  of  the  Lungs 
Partial  Disseminated  Hematogenous  Tuberculosis  of  the  Lungs 

Localized  Pulmonary  Tuberculosis 

Ulcerative  Tuberculosis  of  the  Lungs     ...... 

Mixed  Infection  in  Pulmonary  Tuberculosis 

Fibroid,  Quiescent,  and  Healed  Tuberculosis  of  the  Lungs 


64 
69 
70 

70 
71 
74 

77 
78 


CHAPTER   III 

RESISTANCE,   PREDISPOSITION,   AND   IMMUNITY 

Resistance 80 

Animals  in  General 80 

Man 80 

Individual  Resistance 80 

Normal  Physiologic  Resistance 81 

Influence  of  Age 81 

Influence  of  Heredity 81 

Nature  of  Physiologic  Resistance 82 

Subnormal  Resistance — Predisposition 82 

Influence  of  Sex 83 

Inherited  Predisposition 83 

Inherited  Structural  Defects ■     .  84 

Local  Predisposition 86 

Acquired  Predisposition 87 

Specific  Susceptibility  from  Previous  Tuberculous  Infection     ....  87 

Lymphatic 87 

Pulmonary 88 

Nonspecific  Susceptibility 89 

Infectious  Diseases 89 

Diseases  of  Nutrition 90 

Miscellaneous 91 

Injuries 91 

Increased  Resistance 91 

Physiologic 91 

Occupation 91 

Diathetic 92 

Diseases 92 

Specific  Increase  of  Resistance 92 

Immunity 93 

Experiments 93 

Application 94 

Explanation  of  Mechanism 95 

Specific  Substances  in  the  Blood 96 

Agglutinins  and  Precipitins 96 

Opsonins 96 

Antitoxins 96 

Summary 97 

Addenda 98 


CONTENTS 


XI 


PART    II 
FREQUENCY  AND   DISTRIBUTION 


CHAPTER   I 

FREQUENCY    OF    TUBERCULOSIS 
General  Considerations 
Frequency  in  Autopsies 
Autopsies  in  Children 
Frequency  Intra  Vitam 
"Tuberculosis  a  Children's  Disease" 
Morbidity  Statistics     .... 
Mortality  Statistics  and  the  Decrease  of  Tuberculosis 
Geographic  Distribution 


PAGE 

105 
105 
108 
110 
112 
112 
113 
116 


CHAPTER   II 

TUBERCULOSIS   AMONG    THE    D.\RK-SKINNED    RACES    OF  AMERICA 

Tuberculosis  in  the  Negro         ..." 

Tuberculosis  in  the  Indian .        .        . 

Tuberculosis  Among  the  Japanese  and  Chinese    ...  .        .        . 


121 
127 
129 


CHAPTER    III 

FREQUENCY    OF   TUBERCULOSIS    IN    INSANE   ASYLUMS 

Tuberculosis  in  Hospitals  for  the  Insane 

Diagnosis  of  Tuberculosis  in  the  Insane 

Treatment  of  Tuberculosis  in  the  Insane 

Individual  Treatment 


133 
134 
135 
135 


PART    III 

SYMPTOMATOLOGY   AND  DIAGNOSIS 

INTRODUCTION 


Tuberculosis  in  Childhood 

Portal  of  Entrance  for  Infection 
Other  Portals  of  Entrance 
Clinical  Stages 
Progression  of  the  Infection 

Anergy 

Scrofulosis      .... 
Prophylaxis  and  Therapy  . 


CHAPTER   I 
SYMPTOMATOLOGY   OF    PULMONARY    TUBERCULOSIS 


Introduction  .... 

Chronic  Phthisis  . 
Acute  Phthisis 
Acute  Miliary  Tuberculosis 


142 
142 
143 
143 
144 
146 
147 
147 


149 
150 
153 
155 


Xll  CONTENTS 

PAGE 

Subjective  Symptoms 159 

Fever 159 

Hoarseness 171 

Sweats 171 

Languor 172 

Emaciation 173 

Anorexia 175 

Dyspnea 176 

Cyano.sis 178 

The  Circulatory  System 17S 

Digestive  System 182 

The  Liver 188 

Urinary  System 188 

The  Bones  and  Mu.scles 191 

The  Skin 192 

The  Hair 193 

The  Physical  C'ondition 193 

The  Special  Senses 196 

The  Larynx 197 

Cough 200 

Expectoration 204 

Microscopic  Examination 207 

Hemorrhage 212 

Pain 222 

Objective  Signs 224 

Inspection              224 

Palpation 232 

Mensuration 233 

Percussion 237 

Auscultation 246 

Roentgen  Rays 268 

Blood 285 

Metabolism 292 

CHAPTER    II 

PHYSIC.A.L    EXAMINATION 

Physical  Examination 297 

CHAPTER   III 

DIAGNOSIS 

Sputum  Examination 327 

Physical  Signs 331 

Symptoms  and  Clinical  Course ■       .        .        .        .  335 

Other  Diagnostic  Measures 339 

The  Tuberculin  Test 339 

Modifications  of  the  Tuberculin  Test 346 

Differential  Diagnosis 353 

On  the  Recognition  of  Stages 361 

On  Recording  Findings 374 


CONTENTS  xiii 


PAGE 


Addenda 379 

Symptoms      .                                 379 

Metabolism    .        . 380 

Diagnosis 380 

Diagnostic  Value          .        .        . 380 

Prognostic  Value 3S1 

The  Cutaneous  Reaction 382 

Other  Diagnostic  Methods 334 

Sputum  Examination 355 

Physical  Diagnostic  Measures 335 

Use  of  X-Rays 335 

Prognosis 386 


PART  IV 
PR0PHYL.4XIS   OF  TUBERCULOSIS 

IXTRODUCTIOX 

Introduction 392 

CHAPTER    I 
INDIVIDUAL    PROPHYLAXIS 

Measures  for  the  Healthy  Individual 393 

Infancy 393 

Childhood 397 

Youth 400 

Adult 400 

Measures  for  Tuberculous  Individuals 393 

Closed  Tuberculosis 404 

Scrofulosis 405 

Closed  Pulmonarj^  Tuberculosis 405 

Open  Tuberculosis 405 

Duty  of  Consumptive  Individual  to  Society 408 

Duty  of  Society  to  Consumptive  Individual 408 

Marriage 409 

Addenda 409 

CHAPTER   II 

PUBLIC    MEASURES    IN    THE    PROPHYLAXIS    OF   TUBERCULOSIS 

Historical  Review 410 

Handbills  and  Invitations  to  Lectures 414 

Economic  Loss  to  the  Commonwealth  through  Tuberculosis  .        .        .414 

Protest  Against  Patent  Medicines  and  "Sure"  Consumption  Cures        .        .  410 

Character  of  Tuberculosis  Lecture 416 

Unjustified  Prejudice  against  Consumptives 417 

Federal  Phthisiophobia 418 

State  Phthisiophobia— Goodsell-Bedell  Law 420 

Results  of  Federal  and  State  Phthisiophobia 422 


XIV  CONTENTS 

PAGE 

Law  of  Mexico  as  a  Contrast  to  the  Goodsell-Bedell  Law       ....  423 

Journals  Devoted  to  the  Prevention  of  Tuberculosis 424 

The  Public  Press  and  Tuberculosis 424 

Tuberculosis  Exhibits,  etc 425 

Tuberculosis  Clinic 433 

Advice  and  Care  Stations 438 

Seaside  and  Inland  Sanatoria  for  Tuberculous  Children 439 

Day  Camps 440 

New  York's  Ferryboat  Day  Camp 441 

Class  Method  at  Home 441 

Special  Relief  Work  of  Tuberculosis  Committee  of  the  C.  ().  S.,  New  York      .  442 

Maternity  Sanatoria 444 

Medical  Mission  of  the  Tuberculosis  Sanatorium 445 

Social  Mission  of  the  Tuberculosis  Sanatorium 445 

Duty  of  the  Municipality  toward  the  Family  of  the  Consumptive      .        .        .  44(3 

Preventatorium 440 

Agricultural  and  Horticultural  Colonies 447 

Remuneration  of  Physicians  in  Public  Tuberculosis  Institutions                     .  447 
Compulsory  Notification  of  Tuberculosis  Cases  and  the  Work  of  the  Health 

Department  in  Relation  Thereto 447 

Compulsory  Registration  in  the  United  States  Considered  by  a  Layman     .  458 

Care  of  Tuberculous  Federal  Employees 463 

Care  of  Tuberculous  Insane 463 

Care  of  the  Tuberculous  in  Almshouses,  Asylums,  and  Boarding  Schools        .  465 

Tuberculosis  in  Prisons  and  Reformatories 465 

Tuberculosis  and  Domestic  Animals 473 

Supervision  of  Slaughter-houses 474 

Protection  against  Infection  from  Tuberculous  Milk 474 

Housing  of  the  Masses,  Good  Tenement-house  Laws  and  their  Strict  Enforce- 
ment Essential 477 

Parks  and  Playgrounds 478 

Emigration  from  City  to  Village 479 

Creation  of  Schools  of  Forestry  and  the  Preservation  of  Forests  .        .  479 

Sanitation  at  Home 481 

Window  Tent  for  the  Open-air  Treatment  at  Home 482 

Dry  Air  and  the  Danger  from  Overheated  Dwellings 486 

Danger  from  Dry  Sweeping 486 

The  Common  House-fly  as  a  Propagator  of  Tuberculosis          ....  487 

Prevention  of  Tuberculosis  in  the  School  Child 488 

Sanitation  of  Workshops,  Factories,  Sto;-es,  etc. 492 

Antituberculosis  Work  Among  Factory  Workers 492 

Insurance  against  Tuberculosis 493 

Addenda 495 

Economic  Meaning  of  Tuberculosis 495 

Raising  of  Funds  for  Tulierculosis  Propaganda 495 

Special  Dispensaries 496 

Compulsory  Examination  of  Children 496 

Day  and  Night  Camps 497 

Administrative  Control ....  497 

Naval  and  Military  Prophylaxis       ...                                 ...  497 

Prison  Prophylaxis 498 


CONTENTS  XV 

PAGE 

Prostitution 498 

Children's  School  Farms 498 

Trained  Nurses 499 

Public  Schools,  Colleges,  etc 499 

Insurance  of  Workingmen  against  Sickness 500 

Resolutions 500 


PART   V 
TREATMExXT 

INTRODUCTION 

Introduction 505 

CHAPTER   I 

SPECIFIC   TREATMENT 

Historical  Introduction 508 

Schema  for  Tuberculins  and  Tubercle  Bacillus  Vaccines 511 

Varieties  of  Tuberculin  Used  Clinically 515 

Chemistry  of  Tuberculin 517 

Methods  of  Administration 518 

Intravenous 518 

Oral 518 

Inhalation 519 

Dermin 519 

Subcutaneously 519 

Dilutions         .        .  520 

Preservation  in  Dilution 520 

Method  of  Diluting 520 

Diluents 521 

Estimating  Dilutions 521 

Preparations  for  Injections        .        .       _ 523 

Cleansing  of  Skin 523 

Needles 523 

Accidental  Inoculation 523 

Site  of  Injection 523 

Dosage  and  Interval 524 

General 524 

Beginning  Dose 524 

Interval 525 

Increase  of  Dose 525 

Time  of  Injection 527 

Record  of  Treatment 527 

Typical  Reaction 529 

Skin  Reaction 530 

Organ  Reactions 531 

Localizing  Symptoms 531 

General  Symptoms ...  532 

Temperature ...  532 

1 


XVI  CONTENTS 

PAGE 

Antipyretic  Action 534 

Increased  Susceptibility 534 

Pulse 534 

Weight 534 

Complications 535 

Final  Dose 535 

Hypersusceptibility 538 

Value  of  Small  Doses 538 

Schemata 539 

Selection  of  Patients 541 

Theory  of  Action 541 

Symptoms  and  General  Condition 543 

Elevated  Temperatures 543 

Complications 544 

Physical  Signs 544 

Duration  of  Disease 545 

Age 545 

Prophylactic  Use 545 

Advice  for  Inquiring  Patients 545 

Selection  of  Tuberculin 545 

Duration  of  Treatment 548 

Repeated  Courses 549 

Tuberculin  Test 549 

Treatment  During  the  Administration  of  Tuberculin 550 

Sanatorium 550 

Rest  and  Exercise 550 

Rise  of  Temperature 550 

Medicinal 550 

Vaccines 551 

Effects  of  Repeated  Doses 551 

Weight 551 

Blood 551 

Mobilization  of  Tubercle  Bacilli 553 

Sputum 553 

Urine 554 

Elevated  Temperature 554 

Hemoptysis 555 

Physical  Signs 555 

Complications 555 

Pathologic  Changes 555 

Experimental  Results ,        .        .        .  556 

Results 556 

Reports  of  Tuberculin  Treatment 560 

Loss  of  Tubercle  Bacilli 564 

Antagonistic  Bacteria 565 

Bacterium  Termo 565 

Erysipelas 565 

Syphilis 565 

Yeast 566 

"Acid-fast"  Bacteria 566 

Attenuated  Tubercle  Bacilli 566 


CONTENTS  xvii 

PAGE 

Vaccination 567 

Products  of  the  Tubercle  Bacillus 567 

Organotherapy 568 

Lungs 568 

Lymphatic  Glands 569 

Muscle 570 

Blood  Cells 570 

Hemotherapy 571 

Serotherapy 571 

Varieties 572 

Administration 572 

Results •   ....  573 

Serum  Disease 573 

Maragliano's  Serum 573 

Marmorek's  Serum 574 

Antistreptococcic  Serum 575 

"False  Specifics" 575 

Creosote  and  its  Derivatives 576 

Arsenic  and  its  Derivatives 577 

Alcohol 578 

Drugs  that  Produce  Leucocytosis .  579 

Ichthyol 581 

lodin 581 

Silver 582 

Lecithin 582 

Calcium 582 

Strychnin 583 

Inhalations 583 

Sprays 584 

Injections 584 

Addenda 585 

CHAPTER   II 

SPECIFIC   THERAPEUTICS    OF    MIXED    AND    CONCOMITANT    INFECTIONS 

Specific  Therapeutics  of  Mixed  and  Concomitant  Infections     ....  589 

CHAPTER   III 

HYGIENE.    DIET     AND    OPEN    AIR    IN    THE   TRE.\TMENT    OF   TUBERCULOSIS 

Home  Treatment  by  Sanatorium  Methods 

Food 601 

Milk 603 

Eggs 603 

Meat 604 

Prepared  Foods ...  604 

Alcohol ...  604 

Carbohydrates ...  605 

Dietaries 605 

Air  and  Environment 608 


XVIU 


CONTENTS 


Rest  and  Exercise 

Clothing 

Hydrotherapy  and  Hardening  . 
Symptomatic  Treatment 

Debility  and  Loss  of  Appetite  and  Weight 

Anemia  .... 

Fever      

Cough      

Night  Sweats 

Gastro-intestinal  Disturbances 

Hemorrhage  .... 

Cardiac  Weakness  and  Dyspnea 
Complications        .... 

Insomnia        .... 

Pain 

Pleurisy  with  Effusion 

Empyema       .... 

Pneumothorax 

Pityriasis  versicolor 

Ischiorectal  Abscess     . 

Tuberculous  Laryngitis 

Diarrhea         .... 


The  Sanatorium,  its  Construction  an 
Requisites  of  the  Sanatorium  .... 
Selection  of  Sanatorium  Site  .... 
Planning  and  Construction  .... 
The  Administration  Building  .... 
General  Planning  of  the  Sanatorium  Building 
Building  Material  and  Cost  .... 
Management  and  Sanatorium  Regime    . 


D  Management 


PAGE 

612 
616 
617 
618 
618 
620 
622 
624 
628 
629 
631 
634 
635 
635 
636 
636 
637 
637 
637 
637 
638 
639 


641 
643 
645 
657 
658 
658 
661 


CHAPTER  IV 

CLIMATIC    TREATMENT 

The  Physiology  of  Climate 

Relations  of  Climate  to  Physical  and  Psychical  Condition       ....  663 

Cla.ssification  of  Climates 666 

Effect  of  Excessive  Illumination 670 

High  Altitudes 671 

The  Principles  of  Physiologic  Rest 679 

Climatic  Therapeutics 

Historical  Aspects 680 

General  Definition  of  Climatotherapy 682 

Is  there  a  Specific  Climate  for  Pulmonary  Tuberculosis?  ....  682 

Principal  Types  of  Climate 684 

Ocean  Climates 684 

Inland  Climates 686 

General  Utilization  of  Climatic  Treatment    ........  690 


CONTENTS  xix 

PAGE 

Open  and  Closed  Resorts 692 

The  Selection  of  a  Special  Climate  or  Resort 696 

Enumeration  of  Resorts 697 

United  States  Resorts 700 

The  Adirondack  Mountains 701 

New  Jersey >        .        .  702 

Pennsylvania 703 

Blue  Ridge  Mountains 703 

Appalachians 703 

Florida • 706 

Rocky  Mountain  Resort  Region 707 

Colorado ......  707 

New  Mexico 710 

.Arizona 713 

California 714 

Foreign  Resorts 717 

Mexico    . 717 

Canada 718 

Madeira 718 

Canary  Islands 718 

Europe 718 

Southern  Spain 719 

Africa 719 

Russia 719 

Addenda 720 


PART   VI 
SURGICAL  TUBERCULOSIS 

CHAPTER   I 

TUBERCULOSIS    OF    THE    LYMPH    GLANDS 


Tuberculosis  of  the  Lymph  Glands 

Etiology 

Symptoms  and  Diagnosis  .... 

Treatment 

Tuberculosis  of  the  Cerv^ical  Lymph  Glands 

Tuberculous  Infection  of  the  Lymph  Glands  of  the  Groin 

Tuberculosis  of  Lymph  Nodes  in  the  Axillary  Region 


723 
724 
725 
726 
728 
729 
730 


CHAPTER   II 

TUBERCULOSLS   OF   BONES   AND   JOINTS 

Tuberculosis  of  Bones ....  731 

In  the  Arterioles 732 

In  Venous  Terminals 732 

Treatment 733 


XX  CONTENTS 

PAGE 

Tuberculosis  of  Special  Bones 733 

Cranial  Vault 733 

Ribs -734 

Sternum 734 

Vertebrae 734 

Tuberculosis  of  Joints 735 

Symptoms 735 

Prognosis 736 

Diagnosis 738 

Treatment 739 

Tuberculosis  of  Shoulder  Joint 742 

Occurrence 742 

Symptomatology 742 

Differential  Diagnosis 743 

Prognosis 743 

Treatment 743 

Tuberculosis  of  Carpus  and  Tarsus 743 

Tuberculosis  of  Hip-joint 744 

Sequestra 745 

Symptoms 746 

Diagnosis        .   * 747 

Treatment 747 

Tuberculosis  of  Knee-joint 748 

CHAPTER   III 
PRIMARY   TUBERCULOSIS    OF   MUSCLES    AND   FASCIiE 

Tuberculosis  of  Fasciae 750 

CHAPTER   IV 
TUBERCULOSIS   OF   THE    BRAIN    AND    ITS   MEMBRANES 

The  Meninges 751 

Diagnosis 751 

Symptoms 751 

Treatment 752 

The  Brain 754 

Tuberculomas 754 

CHAPTER   V 

INTESTINAL   TUBERCULOSIS 

General  Considerations 756 

Frequency 758 

Enterogenous 759 

Etiology • 761 

Ulcerative 761 

Hypertrophic  Variety 762 

Location 764 

Treatment 764 


CONTENTS  xxi 

CHAPTER  VI 
TUBERCULOUS   ISCHIORECTAL   ABSCESS   AND   ANAL   FISTULA 

PAGE 

Pathology 766 

Symptoms  and  Diagnosis 766 

Treatment 768 

CHAPTER   VII 

TUBERCULOSIS    OF   THE   PERITONEUM 

Occurrence 771 

Classification 771 

Symptomatology 772 

Diagnosis 774 

Treatment 775 

CHAPTER   VIII 

TUBERCULOSIS   OF   THE   GENITO-URINARY   SYSTEM 

General  Considerations 777 

Tuberculosis  of  the  Testicles 778 

Pathology 779 

Symptoms 779 

Diagnosis 780 

Treatment 781 

Tuberculosis  of  the  Seminal  Vesicles  and  Prostate 784 

Symptoms 785 

Treatment 785 

Tuberculosis  of  the  Kidney 785 

Pathology 786 

Symptoms 787 

Diagnosis 788 

Treatment 788 

Tuberculosis  of  the  Suprarenal  Gland 791 

Tuberculosis  of  the  Bladder 791 

Symptoms 791 

Diagnosis 792 

Treatment 792 

Tuberculosis  of  the  Urethra 794 

Tuberculosis  of  the  Genital  Tract  in  Women 794 

Pathology 794 

Symptoms  and  Diagnosis 794 

Treatment "        ■  794 

Addenda 795 


\ 


xxii  CONTENTS 

APPENDICES 
APPENDIX   I 

PAGE 

The  Tuberculo-Opsonic  Index 799 

APPENDIX   II 
Tuberculosis — A  Leaflet  for  Teachers 804 

APPENDIX   III 

Facts  a  Mother  Should  Know  Concerning  Tuberculosis 808 

APPENDIX    IV 
An  Act .        .     811 

APPENDIX   V 

Instructions  for  the  Physician's  Use  in  Private  Practice  .  .        .     813 

APPENDIX    VI 

Formulary  for   the  Symptomatic  Treatment   of   Pulmonary  and   Laryngeal 

Tuberculosis 819 

APPENDIX   VII 

Devices  for  the  Cure  and  Prevention  of  Tulierculosis 832 

APPENDIX  VIII 
Diet  Lists 852 

BIBLIOGRAPHY 861 

INDEX 905 


LIST   OF   COLORED   PLATES 


PLATE  I 


FACING 
PAGE 

.  198 


1. — Tablelike   Thickening   and   Elevation   of    the    Mucous    Membrane 
of  the  Posterior  Commissure. 
— Small  Erosions  or  Ulcers  of  Free  Border  of  the  Cords,  giving  the 
Characteristic  "  Nibbled-out  "  Appearance. 

3. — Thickening  of  the  Right  False  Cord  which  Overlaps  and  Hides 
Most  of  the  True  Cord. 

Thickening  and  Injection  of  Insertion  of  Cords  and  Small  Ulcer  at 
the  Base. 

Superficial  Erosion  of  the  Upper  Surface  of  the  Vocal  Cords,  Very 
Typical  of  Tuberculosis. 
6.— Grayish  WrinkUng  of  the  Posterior  Commissure,  not  Diagnostic, 
but  Very  Suspicious  if  Combined  with  Other  Symptoms. 
— Ulceration  of  the  Free  Border  of  the  Right  Cord,  Producing  the  Ap- 
pearance of  a  Reduction  of  the  Cord. 
— Wartlike  Growth,  Rising  from  the  Posterior  Commissure  Near  the 
Insertion  of  the  Cord. 


PLATE   II 
1. 


592 


Shows  in  the  Same  FielcJ  Pus  Cells  containing  Tubercle  Bacilli 
and  Streptococci. 

2. — Organisms  Similar  to  (1),  but  Contained  in  the  Same  Pus  Cell. 

3. — A  Large  Pus  Cell  Containing  a  Tubercle  Bacillus  and  Many  Staphy- 
lococci. 

4. — Pus  Cells  Containing  Staphylococci,  Pneumococci,  and  One  C'ell 
Containing  a  Tubercle  Bacillus  and  Pneumococci. 

5. — The  Micrococcus  Catarrhalis  and  the  Pneumococci  and  Tubercle 
Bacilli. 

6. — The  Influenza  Bacillus. 


PLATE   III 

1. — Tuberculosis  of  the  Kidney,  Showing  Cavities  and  Nodules. 
2. — Tuberculosis  of  Lymph  Node,  Showing  Caseous  Nodules. 
3. — Tuberculosis  of   Epididymis,    Incision   through    Normal   Body   of 
the  Testis. 


786 


LIST  OF  ILLUSTRATIONS  IN  TEXT 


1. — Tongue  and  Tonsils  of  Swine  Infected  by  Feeding  Tubercle  Bacilli  36 

2. — Lungs  of  Swine  Infected  by  Feeding 37 

3-4. — Tuberculosis  of  the  Intestines  and  Lungs  of  Monkey  Fed  with  Tubercle 

Bacilli 41 

5. — Tubercle  in  Lung  Tissue 57 

6. — -Tuberculous  Pneumonia  and  Conglomerate  Tubercles     ....  69 

7.— Section  through  Lung,  Showing  Caseous  Tuberculous  Lymph  Glands     .  73 

8. — Tuberculous  Pneumonia  in  a  Child  Thirteen  Months  Old  ....  74 

9. — -Cavity  from  Breaking  Down  of  Tuberculous  Pneumonia  ....  74 

10. — Tuberculosis  of  Eleven  Years'  Standing 76 

11. — Normal,  Well-developed  Upper  Thoracic  Opening  with  Good  Pronun- 
ciation of  Paravertebral  Spaces 99 

12.^ — -Typical  Stenosed  Upper  Thoracic  Opening  with  Asymmetry    ...  99 
13. — Asymmetrical  Thoracic  Opening  with  Slight  Scoliosis  of  Cervical  and 

Upper  Thoracic  Spine 100 

14. — Formation  of  True  Joints  with  Epiphyses  and  Capsules    ....  100 
15. — Distribution  of  Tuberculosis  at  the  Various  Age  Periods  in  a  Series  of 

1,400  Autopsies 108 

16. — Cutaneous  Tuberculin  Reaction  in  1,407  Children Ill 

17. — Cutaneous   Tuberculin   Reaction    in    1,134    Clinically   Nontuberculous 

Children Ill 

18. — The  Age  Distribution  of  Consumption  Mortality 114 

19. — Proportions  of  Deaths  from  Pneumonia  and  Consumption  at  Certain 

Ages 115 

20. — Comparative  Mortality  from  Consumption  of  Whites  and  Blacks   .        .  124 

21. — Treatment  of  the  Tuberculous  Insane  on  an  Open  Porch  ....  136 

22. — A  Cold-proof  Sleeping-bag  and  Method  of  Adjustment       ....  137 

23. — Treatment  of  the  Tuberculous  Insane  in  a  Solarium 138 

24. — Stage  I.     Tyisicai  Moderately  Subnormal  Temperature  (Chart)      .        .  159 
25. — Stage  I.     Marked  Subnormal  Temperature  in  Young  Woman  of  Very 

Poor  Vitality  (Chart) 160 

26. — Stage  11.     Slowly  Spreading  and  with  Gradually  Rising  Fever  (Chart)  160 

27. — Stage  III.     Extensive  Lesions  with  Normal  Temperature  (Chart)          .  161 
28. — Stage  III.     Active  Spreading  Process  in  Both  Lungs  and  Commencing 

Cavity  Formation  (Chart) 162 

29-30. — Non-re.solving  Tuberculous  Pneumonia  with  Chills,  Sweats,  Hectic 
Fever,  and  Rapid  Breaking  Down  of  Lung,  with  Mixed  Infection 

(Chart) 163 

31-32. — Stage  III.    Inactive,  Showing  Effect  of  Overexertion  (Railroad  Jour- 
ney) and  of  an  Acute  Bronchitis  (Chart) 166 

XXV 


xxvi  LIST   OF    ILLUSTRATIONS   IN   TEXT 

FIGURE  PAGE 

33. — Stage  II.     Showing  Effect  of  Intercurrent  Broncho-pneumonia  on  Fever 

Curve  (Chart) 167 

34. — Stage  III.     Shows  Effect  of  Absohite  Rest  in  Bed  on  the  Fever  in  a  Pa- 
tient who  had  been  Exercising  Freely  (Chart) 168 

35. — Temperature  Chart  for  Seven  Months,  Showing  Various  Incidents  in  the 

Course  of  the  Disease,  with  Final  Improvement         .        .        .        ,170 
36-38 — Rapidly  Destructive  Process  of  but  Six  Weeks'  Duration,  but  Re- 
sembling an  Advanced  Chronic  Case 225 

39-41. — Shows  Chest   Outlines  and   Limitations   of  Resonant  Area,   Right 

Shoulder  Droop 227 

42-43. — Prominent  Angle  of  Louis  and  Funnel  Below  It 229 

44. — Cyrtometer  Tracing  of  Incipient  Case  (I) 234 

45. — Case  in  I.  Stage  (R).     Re-expansion  after  Five  Months  (Broken  Line) .  234 

46. — Active  Recent  Disease  on  Left  Side,  Arrest,  and  Final  Cure    .        .        .  234 

47. — Marked  Shrinkage  in  Incipient  Left-sided  Case  (I) 234 

48. — Fibroid  Disease,  Continually  Improving 235 

49.— Stage  III.     Patient  Failing 235 

50.— Round  Type  of  Chest 236 

51. — "Pigeon  Chest,"  Case  in  Stage  III 236 

52.— Flat  Type  of  Chest 237 

53. — Bulging  Backward  on  Account  of  Scoliosis 237 

54. — Marked  Shrinkage  of  Left  Side,  Due  to  Post-pneumonic  Emphysema  .  237 
55.— -Tuberculosis  of  Tracheobronchial  Lymph  Glands  in  Child  Four  Months 

Old 242 

56. — Posterior  View  of  the  Lungs  in  an  Acute  Active  Case,  Showing  Mul- 
tiple Cavities  in  the  Infiltrated  Upper  Left  Lobe        ....  269 

57. — Anterior  View  of  an  Old  Chronip  Process 270 

58. — Anterior  View  of  an  Extensively  Involved  Left  Lung        ....  273 
59.- — Anterior  View  of  the  Lungs  in  a  Case  of  Early  Acute  Tuberculosis  of 

the  Left  Lung 275 

60. — Anterior    View,    Showing    Enlargement    of    the    Peribronchial    Glands 

Around  the  Roots 277 

61.^ — ^Anterior  View  of  the  Lungs  in  an  Old  Case  of  Nineteen  Years'  Standing  279 
62. — A  Posterior  View  of  an  Infiltrated  Left  Apex  with  Slight  Retraction  of 

the  Heart  to  the  Left 281 

63.— Anterior  View 282 

64. — Anterior  View  of  the  Lungs  in  a  Case  of  Pleurisy  with  Effusion  at  the 

Right  Base 284 

65-66. — Proper  Position  of  the  Fingers  and  Wrists 309 

67. — To  Show  the  Use  of  the  Little  Finger  in  Delicate  Percussion    .                 .  310 
68-69.^ — -Fibroid  Tuberculosis  of  Six  Years'  Duration  in  a  Man  of  Fifty-six, 

in  which  the  Fat  Hides  the  Shrinkage  of  the  Chest  .  .        .311 

70-71. — To  Show  the  Deforming  Effect  of  Pulmonary  Tuberculosis  Upon 

the  Thorax 312 

72-73.— Tuberculosis  of  Left  Apex 313 

74-77. — Typical  Case  of  Fibroid  of  Left  Lung  in  Case  of  Four  Years'  Duration  315 

78. — Tuberculin  Injection  with  Negative  Result  .......  345 

79. — Mild  Reaction  after  Fourth  Injection 345 

80. — Mild  Reaction  after  Second  Injection    ........  345 

81. — -Active  Reaction  after  Third  Injection 345 

82.^ — After  First  Injection,  Pseudo-reaction  from  Parulis 345 


LIST    OF   ILLUSTRATIONS   IN  TEXT  xxvii 

FIGURE  PAGE 

345 


83. — Tuberculin  Diagnosis  in  Neurasthenia 

84-85. — Suspect  Case  in  Anemic,  Slender  Youth  (Diagrams)     . 

86-87. — Incipient  Case  (Diagrams) 

88-89. — Incipient  Case,  Chiefly  Posterior,  Extent  I  (Diagrams) 

90-91. — Stage  I  (Diagrams) 

92-93. — Stage  I  (Diagrams) 

94-95.— Incipient  Bilateral  Case  (Diagrams) 

96-97. — Incipient  Case,  but  with  Disseminated  Lesions  and  Laryngeal  In 
volvement 

98-99.— Stage  II  (Diagrams) 

100-101. — Stage  II.     Left  Basal  Pleurisy  and  Limited  Motion  (Diagrams) 
102-103. — Stage  II.     Of  Long  Duration,  with  Retrogressions  and  Exacerba 

tions  (Diagrams) 

104-105. — Stage  II.     Beginning  Softening,  Later  Excavation  (Diagrams) 
106-107. — Stage  II  (Possibly  III).     Beginning  Softening  (Diagrams) 
108-109.— Stage  III  (Left),  I  (Right).     Fibroid  Phthisis  (Diagrams) 
110-111. — -Stage  III.     Softening  of  Consolidated  Right  Apex  (Diagrams) 
112-113.— Stage  III  (R.  Ill,  L.  I).     Cavity  R.  U.  A.  (Diagrams) 
114-115.— Stage  III.     Cavity  (R.)  and  Fluid  at  Base  (L.)  (Diagrams)      . 
116-117. — Stage  III.     Rapidly  Spreading,  Softening  (Diagrams) 
118-119.— Acute     Tuberculous    Pneumonia,    Stage    III,    Illness    Six    Weeks 

(DiagT-ams) 

120-121. — Acute  Miliary  Tuberculosis  (Diagrams) 

122. — Playground  on  Roof  of  Residence  in  New  York  City 

123. — Sleeping  Balcony 

124-125. — Cottage  Showing  Arrangement  for  One  Sleeping  Porch 
126-127. — Cottage  Showing  Arrangement  for  Two  Sleeping  Porches 


128-130. — Exhibition  of  International  Tuberculosis  Congress,  1908  .      426-427 

131. — An  Effective  and  Inexpensive  Method  of  Tuberculosis  Propaganda        .  432 

132. — Exterior  of  Tuberculosis  Clinic  of  New  York  Health  Department    .        .  435 

133. — Floor  Plan  of  Tuberculosis  Clinic  of  New  York  Health  Department     .  436 

134. — Signboard  for  Dispensary  Waiting  Room 437 

135. — Open-air  Treatment  of  Surgical  Tuberculosis    at    Sea  Breeze,  Coney 

Island 440 

136.— B.  Frankel's  Mouth  Mask  for  the  Prevention  of  Drop  Infection       .        .  469 

137.— Window  Tent  in  Use 482 

138.— Window  Tent  Raised,  When  Not  in  Use 483 

139.— Window  Tent 484 

140. — Diagram  Showing  ^^entilation  of  \yindow  Tent 484 

141-142.— Woolen  Hoods  for  Outdoor  Sleeping 485 

143. — First  and  Second  Breathing  Exercise 490 

144.— Third  Breathing  Exercise 490 

145. — Breathing  Exercise  with  Rolling  of  Shoulders 491 

146. — Exercise  for  Children  in  the  Habit  of  Stooping 491 

147. — Tnstrumentarium  for  Tuberculin  Injections 521 

148. — Conditions  on  Discharge,  Expressed  Proportionally,  of  Patients  in  the 

Incipient  Stage,  Treated  with  Tuberculin 557 

149. — Conditions  on  Discharge,  Expressed  Proportionally,  of  Patients  in  the 

Moderately  Advanced  Stage,  Treated  with  Tuberculin 
150.— Proportions  of  Dead  and  Living  in  1906  of  all  those  Treated  with  Tuber 

culin •    • 


365 
365 
366 
366 
367 
367 

368 
368 
369 


369 
370 
370 
371 
371 
372 
372 
373 

373 
374 
401 
402 
403 
404 


xxviii  LIST   OF   ILLUSTRATIONS   IN  TEXT 

FIGURE  PAGE 

15L— Showing  the  Numbers  per  Thousand  Surviving  at  the  End  of  One,  Two, 
Three,   etc..    Years   after   Leaving   the   Adirondack   Cottage   Sani- 
tariums        558 

152. — Grade  I.     Baskets  Holding  about  Twelve,  Eighteen,  and  Twenty-four 

Pounds  of  Mold  or  Other  Material 613 

153. — Shovels  and  Spades  Used  in  Grade  2  and  3  for  Digging  Earth  and  Lifting 

It  Into  Barrows 614 

154. — Forks  of  Different  Weight  for  Graduated  Work  in  Grade  2      .        .        .      615 
155. — Pickaxes  of  Various  Weights  Used  in  Grade  4  for  Breaking  Ground, 

Excavating,  etc 616 

156. — Dr.  Millet's  New  Modified  Shack  for  One  Patient  at  Brockton,  Mass.    .      647 
157. — Open-air  Gallery  Joining  Two  Buildings.     Gaylord  Farm  Sanatorium, 

Wallingford,  Conn 648 

158. — Dr.  King's  Original  "Lean-to"  for  Eight  Patients  at  Loomis  Sana- 
torium, Liberty,  Sullivan  County,  N.  Y 648 

159. — Two  "Lean-tos"  of  the  Loomis  Sanatorium 649 

160. — -Dr.    King's  Modified  and   Enlarged   "Lean-to"   for   Sixteen   Patients. 

Loomis  Sanatorium 649 

161. — Interior  of  Sitting  Room,  Showing  Locker,  Toilet,  and  Bathrooms  in 

the  Rear  in  Sixteen-bed  "Lean-to."     Loomis  Sanatorium       .        .      650 
162. — -One  of  Two  Sleeping  Galleries  of  Dr.  King's  Sixteen-bed  "Lean-to"      .     651 
163. — Open-air  Pavilion  Connected  with  Main  Building.     Maine  State  Sana- 
torium          652 

164. — -Dr.  Holden's  Open-air  Pavilion,  Agnes  Memorial  Sanatorium,  Denver, 

Colo.    . 652 

165. — Floor   Plans   of   Dr.    Holden's   Open-air   Pavilion   at  Agnes  Memorial 

Sanatorium 653 

166. — Boston  Consumptives'  Hospital  at  Mattapan 654 

167. — -Boston  Consumptives'  Hospital  at  Mattapan 654 

168. — Boston  Consumptives'  Hospital  at  Mattapan.     Day  Camp       .        .        .     655 

169. — Boston  Consumptives'  Hospital  at  Mattapan 655 

170. — Main   Building   (Floor   Plan   of  First   Story)   for   Sanatorium   for   100 

Patients 656 

171. — Main  Building  (Floor  Plan  of  Second  Story)  for  Sanatorium  for  100 

Patients 657 

172.— Type  of  Sixteen-bed  "Lean-to,"  H.  M.  King 658 

173. — Floor   Plan   of   First   Floor   of   Administration   and   Infirmary   Build- 
ings of  Maryland  Tuberculosis  Sanatorium  at  Sabillasville,  Md.      .      659 
174. — Bird's-eye  View  cf  Maryland  Tuberculosis  Sanatorium,  Sabillasville,  Md.     660 
175. — Normal  Surface  Temperature  for  the  Year  in  the  ITnited  States      .        .      699 
176. — -Seasonal  Rainfall  in  American  Health  Resorts,  Compared  with  Phila- 
delphia         700 

177.— Case  of  Pott's  Disease 734 

178. — Characteristic  Position  of  Tuberculous  Hip-joint 744 

179. — Multiple  Fistula  Openings  of  Tuberculous  Knee 747 

180.— Plaster-of-Paris  Splint  with  Fenestra 748 

181. — Indicating  how  the  Urinary  Group  of  Organs  is  Pathologically  Dis- 
tinct from  the  Generative  Group,  with  the  Bladder  as  a  Central 
Point 777 


LIST   OF   ILLUSTRATIONS  IN  TEXT  xxix 

ILLUSTRATIONS   IN   APPENDICES 

FIGURE  PAGE 

1. — The  Completed  Capsule 799 

2. — Aspirating   Supernatant    Liquid  with    Suction  Curley  Pipette  Down  to 

Leucocyte  Zone 800 

3. — Glass  Capsule  Containing  Sterilized  Emulsion  of  Tubercle  Bacilli      .        .  800 

4. — The  Finished  Pipette 801 

5. — Beverley  Robinson's  Zinc  Inhaler 820 

6. — A  Laryngeal  Medicator,  Devised  by  Mannheimer  and  Yankauer       .        .  828 
7-8. — Improved   Wooden   Box   for   Sending   Specimens   of   Sputum   to   the 

Laboratory  for  Examination 832 

9-11. — Knopf's  Pocket  Flask,  Manageable  with  One  Hand,  Showing  Method 

of  Use 833 

12-17. — Pocket  Sputum  Flasks        . 834 

18-20. — Three  Different  Kinds  of  Paper  Pocket  Cuspidors         ....  835 

21. — Pocket  Sputum  Case  of  Paper 835 

22. — Pasteboard  Sputum  Cup  for  Bedside 835 

23. — Aluminum  or  Porcelain  Spit  Cup  for  Bedside 835 

24. — Large    Hygienic    Pasteboard   Cuspidor   for   Use    in    Factories,    Public 

Buildings,  etc 836 

25-26.— Pasteboard  Filler  and  Tin  Frame  Holder  of  an  Individual  Cuspidor 

(Portable) 836 

27. — Crematory  Basket  and  Fillers 836 

28-30. — Sanitary  Cuspidors  to  be  Attached  to  Wall,  Closed,  Open,  and  in  Use  837 

31.— Wall  Cuspidor 837 

32-37. — Elevated  Cuspidors  for  Use  in  Sanatoria  or  Public  Buildings       .     838-839 
38. — Telephone  Fitted  with  Paper  Screen  to  Prevent  Infection         .        .        .  839 
39. — Suction  Mask  for  the  Treatment  of  Pulmonary  Tuberculosis  by  Hy- 
peremia        840 

40. — Suction  Mask  Adjusted  to  Face 840 

41. — Humidifier  for  Hot-air  Registers 840 

42. — Hair  Hygrometer  Registering  Directly  Relative  Humidity       .        .  840 

43. — Reclining  Chair  of  Bamboo,  with  Patient  in  Sleeping  Sack       .        .        .  841 

44.— Reclining  Chair  of  Steel  Tubing 841 

45-47. — Portable  Cot,  Occupying  Little  Space  when  Folded      ....  842 

48. — Rest  Cure  at  Home,  in  a  Wicker  Chair,  Padded  on  the  Inside         .        .  843 

49. — Half-tent  with  Patient  Resting  on  Metal  Reclining  Chair          .        .        .  843 

50.— Steel  Frame  for  Half-tent  Folded  Together 844 

51. — Portable  Tent  Cot,  Opened  and  Folded 844 

52. — A  Simple  Inexpensive  Tent  for  Tuberculous  Patients        ....  845 

53. — Various  Ventilating  Devices  of  a  Tent 846 

54.— Portable  Cottage 847 

55. — Tent  on  Grounds  of  Bellevue  Hospital,  New  York 847 

56.— Irving  Fisher's  Tent 848 

57.— Dr.  Biggs's  Adirondack  Tent  House;  It  can  be  Used  with  Perfect  Com- 
fort During  Eight  or  Nine  Months  of  the  Year 848 

58. — Elevations  and  Floor  Plan  of  Dr.  Biggs's  Adirondack  Tent  Hou.se  .  849 

59.— Plan  and  Section  of  a  Ventilated  Tent 850 

60.— Details  of  Roof  Ventilator  on  a  Tent 851 

61. — Permanent  Arrangement  for  Open-air  Treatment  in  a  Country  Home  .  852 

62. — Original  Sleeping  Balcony  in  Hanover,  Mass 852 


INTRODUCTION 


INTRODUCTIOX 
Rv   WILLIAM    OSLER 

HISTORICAL    SKETCH 

The  history  of  tuberculosis  may  be  read  in  full  detail  in  several 
monographs/  Here  it  will  suffice  to  give  a  brief  sketch  of  the  stages 
in  the  development  of  our  knowledge;  and  perhaps  a  clearer  idea  of  its 
evolution  may  be  had  by  a  division  into  four  periods  corresponding  with 
the  gradual  recognition  of  the  great  facts  in  connection  with  the  disease. 
Wliile  these  epochs  overlap,  each  represents  a  special  contribution. 

Better  than  any  other  acute  infection,  tubercidosis  illu.strates  the 
methods  by  whicli  we  have  slowly  reached  our  present  knowledge.  Dur- 
ing a  prolonged  period  the  objective  features  of  disease  alone  attracted 
attention,  and  the  modes  in  which  it  could  he  recognized  were  system- 
atized and  defined.  For  centuries  diseases  presented  only  this  semeio- 
logical  phase  and  nothing  was  known  of  the  morbid  appearances  or  of 
the  cause,  and  consequently  no  efficient  steps  could  be  taken  for  their 
prevention.  At  the  beginning  of  the  nineteenth  century  most  of  the 
common  infections  had  not  got  beyond  this  stage.  Not  one  illustrates 
more  fruitfully  than  tuberculosis  the  slow  but  sure  advance  of  science 
and  of  its  practical  application  /or  the  benefit  of  humanity. 

I.  Semeiological. — The  title  of  one  of  the  lost  books  of  Democritus, 
On  Those  Who  Are  Attaclced  with  a  Cough  after  Illness,  probably  indi- 
cates that  the  pre-Hippocratic  writers  had  practical  knowledge  of  cer- 
tain features  of  tuberculosis.  In  the  Hippocratic  writings  there  is  much 
of  importance.  The  disease  was  recognized  as  a  fever;  the  association 
with  hemoptysis  and  with  pleurisy  was  known;  an  excellent  description 
was  given  of  the  phthisical  habit  and  of  the  general  appearance  of  the 
chest  and  of  the  bulbous  fingers.  The  cause  was  simple— dropping  of 
the  pituita  from  the  head  into  the  lungs  produced  ulceration  and  fever. 
Galen  did  not  get  much  beyond  the  Hippocratic  standpoint,  but  he  is 
very  specific  in  a  strong  recommendation  of  milk  diet  and  a  dry  climate 
in  the  disease.  The  clinical  picture  by  Aretaeus  is  one  of  the  best  in 
literature.  Celsus,  too,  has  an  admirable  account  and  distinguished 
pulmonary  phthisis  from  the  other  species  of  tabes,   namely,  atrophy 

•  Waldenburg,  Predohl,  Johne  (see  Bibliography). 

3 


4  INTRODUCTION 

and  cachexia.  He  rccoiimioiKlcd  long  sea  vo3'ages,  cliange  of  climate, 
particularly  Egypt,  and  a  milk  diet.  There  are  indications  in  the  old 
Greek  writers  that  they  knew  of  the  contagiousness  of  the  disease.  Not 
much  was  added  to  the  symptomatology  by  the  Arabian  scliool,  which 
followed  slavishly  Hippocrates  and  Galen.  Nor  did  the  writers  of  the 
Renaissance  add  much,  but  Fracastorius  recognized  very  clearly  the  con- 
tagious character  of  the  disease,  regarding  habitual  residence  with  a 
consumptive  as  one  of  the  most  common  sources.  He  insisted  that  the 
germs  could  remain  attached  to  the  clothing  and  rooms  for  a  year  or 
more.  In  the  seventeenth  century  tlie  disease  was  much  more  fully  con- 
sidered, and  special  monographs  liegan  to  be  written.  Among  these 
the  Phthisiologia  of  Richard  Morton,  1089,  is  perhaps  the  most 
important.  He  recognized  the  wide  prevalence  of  tuberculosis  of  the 
lungs:  "  Yea,  when  I  consider  with  myself,  how  often  in  one  year  there 
is  cause  enough  ministered  for  ])ro(lucing  these  Swellings,  even  to 
those  that  are  wont  to  observe  the  strictest  Rules  of  Living,  I  cannot 
sufficiently  admire  that  anyone,  at  least  after  he  comes  to  the  Flower 
of  his  Youth,  can  dye  without  a  touch  of  Consumption."  He  recog- 
nized the  two  types  of  fever,  the  acute  inflammatory  at  the  beginning 
and  the  hectic  toward  the  end.  Altogether,  the  work  indicates  a  wide 
and  accurate  knowledge,  and  the  intestinal,  the  pleural,  and  the  throat 
symptoms  are  well  described.  He  had  a  strong  belief  in  the  curability 
of  consumption  in  its  early  stages,  but  warns  of  its  liability  to  recur. 
From  no  seventeenth-century  work  do  we  get  so  interesting  a  picture 
of  the  knowledge  of  the  period,  and  it  is  from  the  hand  of  a  highly 
educated  physician  of  wide  experience.  IMorton  fully  appreciated,  too, 
the  contagious  nature  of  the  disease  and  gives  some  striking  illustra- 
tions. In  the  writings  of  Sydenham  are  to  be  found  many  interesting 
sections  on  phthisis,  but  his  special  contril)ution  was  the  insistence  of 
the  value  of  fresh  air  and  of  horseback  riding  in  the  treatment  of  the 
early  stages  of  the  disease.  His  remark  on  the  latter  is  worth  quoting: 
"  I  am  sure  that  if  any  physician  had  a  remedy  for  the  curing  of  a 
phthisis  of  equal  force  with  this  of  riding,  he  might  easily  get  what 
wealth  he  pleased." 

If  we  except  Auenhrugger's  invention  of  the  art  of  percussion,  I  do 
not  know  in  the  eighteenth  century  of  any  single  contribution  of  the 
first  rank  to  the  symptoms  or  signs  of  tuberculosis,  and  in  the  popular 
text-books  on  physic  at  the  latter  part  of  the  century,  and  even  in  the 
early  part  of  the  nineteenth  century,  as,  for  example,  Cullen's  "  First 
Lines,"  there  is  not  much  beyond  the  description  given  by  Morton. 
The  modern  study  of  the  clinical  features  of  the  disease  dates  from  the 
publication  of  the  immortal  work,  de  l' Auscultation  Mediate,  1819.  Not 
only  did  Laennec  describe  the  disease  anatomicallv  and  recognize  the 


HISTORICAL   SKETCH  5 

pliysical  signs,  hut  he  gave  us  the  first  careful  study  of  the  healing  of 
tuberculosis,  and  his  article  (1819,  i,  19)  remains  to-day  one  of  the  best 
descriptions,  clinically  and  anatomically,  of  this  process.  We  have  here, 
too,  one  of  the  first,  as  it  is  to-day  one  of  the  best,  accounts  of  the  sputa 
of  consumption.  Within  the  next  fifty  years  the  careful  studies  of 
Andral  and  Skoda,  C.  B.  J.  Williams,  Stokes,  Austin  Flint,  and  many 
others,  gave  clearness  and  accuracy  to  our  knowledge  of  the  symptoms 
and  physical  signs  of  the  disease. 

II.  Anatomical. — Franciscus  Sylvius  (161-1:-1672)  was  the  first  to 
describe  accurately  tubercles  in  the  lungs.  He  attributed  them  to  en- 
largement of  small  glands  following  upon  a  scrofulous  constitution.  He 
knew  that  they  caseated  and  broke  down  to  form  cavities.  He  regarded 
phthisis  as  identical  with  ulcus  puhnonum.  Manget,  in  his  edition  of 
the  Sepulchretum  of  Bonetus,  1700,  described  for  the  first  time  miliary 
tubercles.  In  an  autopsy  of  a  person  dead  of  phthisis  granules  were 
found  in  the  lungs,  liver,  spleen,  kidneys,  mesenteric  glands,  and  intes- 
tines, which  he  compares  to  semen  millii.  Morgagni  did  not  add  much 
of  importance.  He  raised  the  question  whether  the  tubercles  were  really 
glands.  Stark,  Avhose  works  were  published  in  1785,  fifteen  years  after 
his  death,  gave  to  miliary  tuberculosis  its  proper  pathological  and  clin- 
ical position.  Thomas  Eeid,  1785,  insisted  that  the  tubercles  were  not 
really  glands.  Bayle,  1810,  is  the  founder  of  the  modern  patholog}'  of 
tul)erculosis.  He  describes  the  stages  of  development  and  accepts  the 
miliary  tubercle  as  the  starting  point.  At  first  firm,  later  they  soften 
and  are  finally  destroyed  by  suppuration.  Such  tubercles  he  describes 
in  nearly  all  the  organs,  and.  he  recognized  that  in  these  various  parts 
of  the  body  they  were  related,  genetically  and  clinically.  For  him 
phthisis  was  a  general  disease  of  a  specific  nature  and  by  no  means  to 
be  considered  the  result  of  inflammation  of  the  glands  or  of  the  lym- 
phatic system.  The  cheesy  substance  was  a  specific  material  character- 
istic of  the  process.  He  held  that  inflammation  never  caused  tubercu- 
losis and  that  the  hemoptysis  was  the  result  and  not  the  cause  of 
pulmonary  ])hthisis.  Laennec  agreed  with  Bayle  in  regarding  the  miliary 
tubercle  as  the  starting  point,  and  held  that  the  miliary  granule  of 
Bayle  was  simply  the  forerunner  of  the  tubercle,  the  two  bearing  to 
each  other  the  relation  of  green  and  ripe  fruit.  He  recognized  but  one 
cause  of  true  phthisis,  namely,  tuberculosis,  and  he  simplified  very 
much  Bayle's  classification  and  separated  from  the  disease  pulmonary 
gangrene  and  carcinoma.  The  modern  view  of  the  unity  of  phthisis 
dates  from  the  work  of  Laennec.  Great  confusion  arose  in  the  middle 
of  tlie  nineteenth  century  by  Yirchow's  attempt  to  disprove  the  spe- 
cificity of  the  caseous  tubercle  in  which  he  saw  only  one  form  of  tissue 
necrosis.     The  term   tubercle  he  restricted   to   the  miliarv   granule  of 


6  INTRODUCTION 

Bayle  and  Laennec,  and  the  miliary  tubercle  he  classed  with  the  lym- 
phomata,  developing  in  preexisting  lymphoid  tissue.  He  thought  that 
caseation  in  the  lungs  arose  from  other  processes  than  tuberculosis. 
This  led  to  the  heterodox  views  of  Niemeyer  and  others,  who  carried 
the  dualistic  view  to  such  an  extreme  that  they  believed  the  worst  fate 
to  happen  to  a  consumptive  was  for  him  to  become  tuberculous.  In 
1857  Buhl  showed  that  acute  miliary  tuberculosis  was  a  specific  infec- 
tious disease.  In  twenty-three  cases  he  found  in  twenty-one  cheesy 
nodules,  yellow  tubercles,  or  other  tuberculous  foci.  The  specific  virus 
was  regarded  as  coming  from  these  cheesy  nodules  from  which  the  poison 
was  disseminated  throughout  the  body.  This  prepared  the  way  for  the 
third  and  all-important  stage  in  the  history,  and  led  to  the  discovery 
of  the  true  cause  of  the  disease. 

III.  Etiological. — Cruveilhier,  in  1826,  undertook  systematic  inocu- 
lation experiments,  but  he  thought  that  tuberculosis  resulted  from  the 
inoculation  of  a  variety  of  substances  and  was  not  specific.  But  even 
before  this,  in  1789,  Kortum  attempted  inoculation  experiments  with 
scrofulous  material.  In  1843  Klencke  stated  that  tuberculosis  was 
inoculable  and  made  successful  experiments  in  support  of  this  view.  A 
French  army  surgeon,  J.  A.  Villemin,  conclusively  demonstrated  that 
tuberculosis  was  a  specific  infectious  disease.  His  original  paper  was 
read  before  the  Paris  Academy  of  Medicine,  December  4,  1865.  His 
epoch-making  work.  Etudes  sur  Ja  Tuherculose,  published  in  1868, 
is  one  of  the  most  remarkable  contributions  ever  made  to  scientific 
medicine.  The  experiments  were  conducted  with  the  greatest  care  and 
accuracy,  and  his  work  everywhere  shows  the  brilliant  scientific  investi- 
gator. For  the  period  his  conclusions  were  novel  and  far-reaching,  and 
it  is  not  surprising  that  they  were  received  with  a  great  deal  of  scep- 
ticism. First,  tuberculosis  is  a  specific  infection;  secondly,  it  has  its 
origin  in  an  inoculable  agent ;  thirdly,  inoculation  from  man  to  rabbits 
is  very  successful ;  fourthly,  tuberculosis  belongs,  therefore,  to  the  viru- 
lent diseases  and  should  be  classed  with  small-pox,  scarlet  fever,  syphilis, 
and  more  particularly  with  glanders. 

In  1877  Cohnheim  clinched  the  question  of  inoculability  by  his  brill- 
iant experiments  (with  Salomonsen)  in  inoculating  tuberculous  mate- 
rial into  the  anterior  chamber  of  the  eye  of  the  rabbit.  The  sources 
of  error  in  previous  experiments  were  eliminated  and  conclusive  proof 
offered  of  the  specificity  of  tulierculous  material.  Klebs  was  the  first 
to  undertake  feeding  experiments  with  tuberculous  material,  and  he 
was  able  to  really  cultivate  a  vinis  on  egg  albumen  through  several 
generations,  and  he  narrowly  missed  the  detection  of  the  bacillus.  The 
final  etiological  demonstration  was  reserved  for  Koch  in  1883,  who 
Toinid  a  definite  bacillus  in  all  forms  of  tuberculous  lesions.     He  was 


HISTORICAL   SKETCH  7 

able  to  cultivate  the  organism  through  many  generations,  at  the  end  of 
which  it  was  inoculable.  His  observations  were  quickly  confirmed,  and 
it  is  not  too  much  to  say  that  no  single  discovery  in  disease  has  had  a 
more  wide-reaching  influence.  The  remarkable  tuberculosis  campaign, 
inaugurated  in  the  eighties,  derived  its  inspiration  directly  from  his 
work.  Many  minor  points  in  the  etiology  remain  unsettled,  but  the 
great  fact  remains — the  enemy  is  known,  its  life  history  is  known,  the 
mode  of  entrance  into  the  system  is  known,  and  this  has  heen  followed 
by  the  fourth  stage  in  the  history  of  the  disease — the  period  of 

IV.  Prevention. — It  was  the  French  who  awoke  to  the  fact  that  in 
the  fight  against  tuberculosis  organization  was  the  first  essential,  and 
under  the  presidency  of  Chauveau  congresses  were  inaugurated  and  an 
attempt  made  to  influence  public  opinion.  The  past  twenty  years  has 
seen  one  of  the  most  remarkable  revolutions  ever  attempted  in  sanitation. 
Throughout  the  world  the  most  intense  interest  has  been  stimulated 
in  the  fight  against  the  white  scourge.  Governments  have  appointed 
commissions,  local  congresses  have  been  held,  local  societies  formed, 
national  associations  exist  everywhere,  and  an  important  international 
congress  meets  triemiially,  a  permanent  international  bureau  exists,  and, 
above  all,  a  universal  enthusiasm  has  been  aroused  which  has  enabled 
the  battle  to  be  carried  on  with  an  extraordinary  measure  of  success. 

The  three  important  factors  concerned  with  the  effective  prevention 
of  the  disease  are  a  knowledge  of  the  means  of  transmission,  a  recog- 
nition of  the  importance  of  social  and  personal  environments,  and  a 
conviction  that  if  taken  early  and  properly  treated  the  disease  may  be 
arrested  or  cured.  A  knowledge  of  the  sources  of  infection  has  been 
the  most  potent  element  in  the. institution  of  sound  measures  for  pre- 
vention. Hereditary  transmission,  formerly  thought  to  be  one  of  the 
most  important  modes  of  conveyance,  is  now  believed  to  play  a  very 
minor  role.  A  few  cases  of  congenital  tuberculosis  occur,  but  the  num- 
ber reported  in  man  is  very  small.  On  the  other  hand,  a  constitutional 
susceptibility  may  be  transmitted — i.  e..  a  soil  favorable  to  the  growth 
of  the  bacillus.  The  study  of  the  statistics  of  inheritance  in  tubercu- 
losis has  received  a  fresh  impetus  from  the  work  of  Karl  Pearson,  who 
has  applied  the  new  biometric  methods  to  the  problem,  and  his  con- 
clusions conlirm  the  belief,  intensified  in  the  profession  of  late  years, 
as  to  the  importance  of  what  the  French  call  heredite  de  terrain.  He 
concludes  that  the  diathesis  of  pulmonary  tuberculosis  is  undoubtedly 
inherited  and  that  the  intensity  of  its  inheritance  is  comparable  with 
that  found  for  normal  physical  characters  in  man.  After  the  work  of 
Comet  the  belief  became  general  that  tuberculosis  was  transmitted  by 
dust-I)orne  dry  sputum,  and  the  chief  avenue  of  infection  was  through 
the  lungs.     Flugge  modified  this  air-borne  view  by  showing  that  the 


8  INTRODUCTION 

danger  was  not  so  much  from  the  dust  as  from  infected  droplets  of 
mucus  and  saliva  thrown  off  from  the  patient  in  the  acts  of  coughing, 
speaking,  and  sneezing.  Infection  was  also  thought  to  be  derived  from 
the  milk  of  tuberculous  animals.  In  1901  Koch  denied  the  suscepti- 
bility of  human  beings  to  the  bovine  type  of  tuberculosis.  Commissions 
in  Germany  and  England  have  made  exhaustive  reports,  which  on  the 
whole  are  opposed  to  this  view  of  Koch  and  show  that  the  bovine  form 
is  capable  of  transmission  to  the  human  species.  In  recent  study  on 
the  modes  of  infection  von  Behring  discredits  largely  the  dust-borne 
infection,  and  holds  that  the  disease  is  communicated  to  the  child 
through  the  bovine  milk.  The  bacilli  readily  pass  the  intestinal  mucous 
membrane  and  lodge  in  the  lymph  glands  of  the  mesentery  and  of  the 
bronchi,  where  they  remain  latent  until  debilitating  circiimstances — 
an  acute  infection,  for  example,  such  as  measles — afford  an  opportunity 
for  successful  attack  of  the  latent  germs.  The  general  result  of  von 
Behring's  work  has  been  to  call  attention  to  the  frequency  of  infection 
through  the  alimentary  tract,  particularly  in  children,  and  through  the 
tonsils  and  the  glands  of  the  neck. 

Poverty  and  tuberculosis  are  everywhere  associated,  particularly  in 
the  large  centers  of  population.  The  Vienna  figures  quoted  by  Bul- 
strode  (*()8)  illustrate  this  in  a  striking  manner.  In  District  No.  1, 
the  best  portion  of  the  city,  the  death-rate  from  tul)erculosis  was  11 
per  10,000  of  the  population ;  the  income-tax  payers  amounted  to  25 
per  cent  of  the  population,  and  the  illegitimate  births  to  0.8  per  thou- 
sand, whereas  in  District  No.  10,  the  poorest  section  of  the  city,  the 
death-rate  from  tuberculosis  was  67  per  10,000 ;  the  income-tax  payers 
9.2  per  cent  of  the  population  and  the  illegitimate  birtlis  9.2  per  thou- 
sand. This  is  the  case  all  over  the  world,  and  is  brought  out  in  a 
striking  manner  by  the  figures  collected  by  Bulstrode  in  his  report. 
Wherever  the  population  is  so  crowded  that  the  families  live  in  one 
or  two  rooms  the  tuberculous  death-rate  is  fully  doul)le  that  of  districts 
in  which  the  families  live  in  houses  with  four  rooms  and  upward. 
Alcoholism  is  another  factor,  the  importance  of  which  has  been  dealt 
with,  particularly  by  French  observers.  Neither  in  England  nor  in 
America  is  the  available  evidence  so  striking,  but  there  is  no  question, 
I  think,  that  the  chronic  alcoholic  is  more  prone  to  succumb  to  tuber- 
culosis than  the  temperate  man  or  the  teetotaler. 

Of  course  we  have  to  recognize  the  very  widespread  prevalence  of 
infection,  and  only  a  comparatively  few  persons  reach  the  age  of  fifty 
without  a  focus  somewhere  of  tuberculosis.  Niigeli's  estimate  of  ninety 
per  cent  may  l)e  high  for  some  localities,  luit  even  if  we  take  a  moderale 
percentage  of  fifty  it  shows  what  an  enormous  number  of  persons  have  in 
them  the  possibility  at  least  of  liecoming  seriously  diseased.     In  some 


AMERICAN   WORK   ON  TUBERCULOSIS  9 

il  is  a  siiuill  jipical  j)U('kerin<:^.  llic  I'csult  of  a  local  infection  years  before 
indicated  |)erlKi|is  al  the  tiuni  by  some  obscure  illness.  Another  has  a 
small  caseous  focus  iucaj^sulated  beneath  tiie  pleura,  a  third  has  the 
bronchial  glands  involved,  while  a  fourth  has  a  focus  or  two  of  case- 
ation in  the  mesenteric  glands.  Upon  the  personal  hygiene  of  the  indi- 
vidual depends  largely  whether  or  not  he  becomes  consumptive.  All 
debilitating  circumstances  render  the  body  less  able  to  keep  the  invader 
in  check. 

Following  directly  upon  this  increased  knowledge  of  the  etiology 
of  tuberculosis  has  come  the  gratifying  recognition  of  the  curability 
of  the  disease  and  of  the  proper  means  to  be  taken  for  its  prevention. 
We  know  what  the  germ  is  and  how  it  is  transmitted.  We  are  able  to 
take  measures  to  prevent  its  spread  in  the  community,  and  we  know, 
too,  that  the  nature  of  the  soil  is  of  quite  equal  importance  to  the  germ. 
All  this  has  had  a  direct  l)earing  upon  the  measures  taken  for  the  treat- 
ment of  the  disease.  Statistics  show  very  clearly  that  with  the  im- 
provement in  general  sanitation  there  has  been  a  remarkable  reduction 
in  the  death-rate  from  tuberculosis.  The  death-rate  has  fallen  steadily 
in  the  past  sixty  years  from  38.8  per  10,000  in  the  quinquennial  period 
1838-42  to  12.1  per  10.000  in  the  quinquennial  period  1901-1905. 
This  is  an  extraordinary  record  and  almost  justifies  the  hope  that  tuber- 
culosis may  ultimately  come  within  the  category  of  such  diseases  as 
leprosy,  typhus  fever,  and  malaria,  which  have  been  practically  abolished. 
The  early  recognition  of  the  disease  is  now  everywhere  regarded  as  the 
first  essential  in  the  successful  cure  of  a  case.  At  present  we  are  in  the 
sanatorium  phase  of  treatment,  and  from  the  work  of  Brehmer,  Dett- 
weiler,  Trudeau,  and  others  we  have  learned  very  important  lessons  in  the 
proper  management  of  cases.  But  the  disease  is  so  widely  prevalent  that 
we  can  never  hope  to  place  sanatorium  treatment  at  the  disposal  of  more 
than  a  very  small  percentage  of  the  patients.  The  brunt  of  the  battle 
must  be  borne  by  the  practitioners  at  large.  The  better  they  know  the 
disease,  the  better  equipped,  they  are  to  recognize  it  early,  the  more 
intelligently  will  they  appreciate  the  conditions  under  which,  even  in 
homes,  it  may  be  arrested  or  cured. 

AMERICAN   WORK   ON   TUBERCULOSIS 

Some  of  the  7uore  distinguished  American  students  of  tuberculosis 
may  here  he  mentioned.  Benjamin  Hush,  the  American  Sydenham,  was 
a  very  careful  student  of  the  problem,  and  several  of  the  first  papers 
on  the  disease  published  in  America  are  from  his  pen.  He  regarded 
it  as  a  debility  affecting  the  whole  system,  and  the  cough,  ulceration, 
and  purulent  discharges  from  the  lungs  were  the  effects  of  the  disease. 


10  INTRODUCTION 

He  had  Sydenham's  views  of  the  vahie  of  open  air  and  exercise  in 
treatment.  He  doubted  very  much  if  it  was  contagious.  Rush  was 
one  of  the  first  students  of  climatology  in  America.  Samuel  George 
Morton,  the  celebrated  craniologist,  was  a  pupil  of  Laennec,  and  learned 
at  first  hand  from  the  great  master  the  essentials  in  the  pathology  and 
diagnosis  of  the  disease.  In  1834  he  published  a  volume  on  "  Pul- 
monary Consumption"  (the  first  issued  in  the  United  States),  which 
contains  a  great  deal  of  original  matter.  Among  the  American  pupils 
of  Louis,  William  W.  Gerhard  and  Henry  I.  Bowditch  became  the  rec- 
ognized authorities  on  tuberculosis  in  their  day.  In  1842  the  former 
published  a  work  on  the  "  Diagnosis,  Pathologj^  and  Treatment  of  the 
Diseases  of  the  Chest."  He  was  one  of  tlie  first  to  contribute  a  careful 
study  of  tuberculous  meningitis.  Tliroughout  a  long  and  active  life 
Bowditch  was  always  interested  in  consumption.  He  early  introduced 
aspiration  in  pleural  effusion,  and  his  study  of  consumption  in  New 
England  was  a  very  valuable  contribution  to  the  disease.  By  far  the 
ablest  and  most  scientific  of  American  students  of  the  disease  was  Austin 
Flint,  whose  contributions  to  the  physical  signs  and  the  symptoms  were 
among  the  most  important  of  his  many  clinical  studies.  His  work  on 
"  Phthisis  "  is  of  value  to-day.  There  were  many  other  students  of  the 
subject,  but  the  names  I  have  mentioned  are  the  most  important  among 
those  who  have  passed  away.  In  the  past  two  decades  the  United 
States  and  Canada  have  seen  an  astonishing  revival  of  interest  in  the 
disease,  all  aspects  of  which  are  being  studied  with  the  greatest  en- 
thusiasm. 


PART   I 
ETIOLOGY    AND    MORBID    ANATOMY 


CHAPTER   I 

ETIOLOUY— THE    TUBERCLE    BACILLUS 
By  MAZYCK  p.  RAVENEL 

History. — In  1865  Villemin,  in  his  first  communication  to  the 
French  Academy  of  Medicine  on  the  inoculability  of  tuberculosis,  fore- 
shadowed the  nature  of  the  virus  in  the  following  words :  "  Tubercu- 
losis is  the  effect  of  a  specific  causal  agent,  of  a  virus.  This  morbid 
agent  ought  to  be  found,  like  its  congeners,  in  the  morbid  products 
which  it  has  determined  by  its  direct  action  on  the  normal  elements 
of  the  affected  tissues  introduced  into  an  organism  capable  of  being 
affected  by  it.  This  agent  ought  then  to  reproduce  itself,  and  to  repro- 
duce at  the  same  time  the  disease  of  which  it  is  the  essential  principle 
and  the  determining  cause." 

In  1877  Klebs,  studying  tuberculous  products  by  means  of  his 
method  of  fractional  cultures,  obtained  a  growth  to  which  he  gave  the 
name  "  monas  tuberculosum,"  and  which  he  believed  capable  of  repro- 
ducing the  disease  when  injected  intraperitoneally  into  animals.  Schiil- 
ler  ('80)  repeated  the  experiments  of  Klebs,  and  obtained  like  results. 

In  1881  Toussaint  obtained. a  growth  from  tuberculous  products, 
injections  of  which  produced  tuberculosis,  as  proved  by  the  subsequent 
findings  of  tubercle  bacilli  in  the  tissues  of  the  inoculated  animals. 
In  the  light  of  present  knowledge  it  is  evident  that  some  true  tubercle 
bacilli  must  have  been  carried  over  from  his  original  material  into  his 
cultures.  It  remained  for  Robert  Koch,  in  1882,  in  a  masterly  series 
of  studies  to  demonstrate  the  true  nature  of  the  bacillus  of  tubercu- 
losis and  to  obtain  it  in  pure  culture.  The  immense  amount  of  work 
which  has  been  done  since  that  time  has  only  served  to  confirm  the 
accuracy  of  his  discovery  and  to  define  certain  types  of  the  bacillus 
found  in  different  species  of  animals. 

Types  of  Tubercle  Bacillus. — Soon  after  the  announcement  of  Koch's 
discovery,  very  confusing  and  contradictory  results  were  obtained  by 
French  investigators.  Exchange  of  cultures  and  further  experiments 
proved  that  the  French  were  working  with  cultures  obtained  froin  birds, 
which  showed  striking  differences  in  growth  and  virulence  fiotn  the 
mammalian  bacillus. 

13 


14  ETIOLOGY— THE  TUBERCLE   BACILLUS 

Ai-iau  Tuberculosis. — Tuborculo^is  in  birds  differs  markedly  from 
the  disease  as  seen  in  mammals.  It  affects  almost  exclusively  the  organs 
of  the  abdomen,  }3rincipally  the  liver,  which  is  enlarged  and  packed 
with  tuberculous  granules.  The  spleen  is  almost  always  affected,  showing 
small  whitish  nodules.  The  intestine  is  rarely  ulcerated,  but  constantly 
contains  nodules  which  tend  to  occupy  the  serous  surface.  The  most 
striking  peculiarity  is,  however,  that  the  lungs  are  practically  never  in- 
volved. Lesions  of  the  joints,  mouth,  pharynx,  nose,  and  eye  are  met  with. 
Whatever  the  location  or  character  of  the  lesion,  it  contains  myriads  of 
bacilli,  often  so  packed  together  as  to  obscure  the  anatomic  elements. 

Bovine  Tuberculosis. — In  1896  and  1898  Theobald  Smith  called 
attention  to  certain  differences  between  the  tubercle  bacilli  obtained  from 
human  sources  and  those  from  cattle.  These  differences  appear  in  the 
morphology,  cultural  characteristics,  and  staining  reactions,  though  the 
most  marked  feature  is  the  vastly  greater  pathogenic  power  for  prac- 
tically all  experimental  animals  shown  l)y  the  bovine  bacillus. 

Tuberculosis  in  cattle  presents  certain  points  of  difference  from  the 
disease  as  seen  in  man.  Among  these  may  be  mentioned  the  marked 
tendency  of  the  lesions  in  cattle  to  undergo  calcification  rather  than 
caseation,  as  seen  in  man,  and  the  involvement  of  serous  surfaces, 
such  as  the  pleura>,  peritoneum,  etc..  with  the  formation  of  new  growths, 
beginning  as  minute,  gray,  translucent  nodules,  which  increase  in  size 
by  the  proliferation  of  connective  tissue  about  them  and  form  clusters 
which  assume  shapes  like  bunches  of  grapes,  mulberries,  or  a  cauli- 
flower, hence  the  names,  "  Perlsucht,"  "grajjc  disease."  These  new 
growths  are  frequently  very  large,  even  reaching  sixty  pounds  in  weight. 
There  is  also  less  tendency  to  secondary  infections,  and  consequently 
•the  ulcerative  type  of  the  disease  is  not  common,  though  large  caseous 
abscesses  are  frequently  seen  in  the  lungs,  as  well  as  in  other  organs. 

Tuberculosis  is  met  with  in  practically  every  known  animal  which 
has  come  in  contact  with  man.  The  bacillus  isolated  from  these  various 
animals  has  always,  up  to  the  present  time,  belonged  to  one  of  the  two 
types,  human  or  bovine,  and  the  infection  can  often  be  traced  to  one 
or  the  other  source.  No  other  species  of  animal  has  been  found  to  be 
affected  so  constantly  with  tuberculosis  nor  to  harbor  a  type  of  bacillus 
with  such  marked  characteristics  as  to  warrant  a  further  classification 
of  mamnuilian  tubercle  bacilli. 

Other  types  of  tubercle  bacillus  have  been  isolated  from  cold- 
blooded animals,  such  as  the  fish  tubercle  bacilhis  of  Dubard,  that  found 
in  a  turtle  by  Friedmann,  and  that  produced  by  Moeller  by  inoculation 
of  a  slowworm  with  a  mammalian  culture.  These  cultures  approach 
the  acid-fast  group  in  their  characteristics,  and  there  is  no  evidence 
that  they  ever  produce  disease  in  man. 


STAINING  15 

Morphology  of  the  Tubercle  Bacillus. — The  morphology  of  the 
tubercle  bacillus  varies  according  to  its  origin,  the  length  of  time  it 
has  been  grown  on  artificial  culture  media,  the  composition  of  the  cul- 
ture media,  and  the  age  of  the  individual  culture  examined. 

Two  types  of  bacilli  are  found  in  man,  the  human  and  the  hovine. 
The  human  bacillus  is  a  slender  rod  0.3  /x  in  thickness  and  from  1.5  fx. 
to  o  fi  long,  its  length  being  from  about  one  fourth  to  one  half  the  diam- 
eter of  a  red-blood  corpuscle.  Longer  forms  are  sometimes  met  with. 
The  rods  are  straight  or  curved  and  occur  singly,  in  pairs,  or  in  small 
bundles.  In  old  cultures,  filamentous  clubbed  and  branched  forms  are 
not  infrequently  seen.  The  bacilli  often  stain  unevenly,  presenting  a 
beaded  appearance,  due  to  unstained  areas  along  the  rod  with  deeply 
stained  portions  between  them. 

The  bovine  ])acillus  is  shorter  than  the  human  organism,  seldom 
being  more  than  2  ju,  in  length,  and  is  somewhat  thicker.  The  rods  are 
straight  and  often  spindle-shaped.  Very  short  forms  are  common,  the 
length  being  not  more  than  twice  the  thickness.  They  take  the  stain 
evenly  and  deeply,  beaded  forms  not  being  common,  though  sometimes 
seen,  especially  in  tissues. 

The  two  types  are  quite  tenacious  of  their  characteristics,  but  tend 
to  approach  each  other  under  prolonged  cultivation,  the  bovine  bacillus 
coming  to  resemble  the  human  more  closely. 

Capsules  of  Schron. — These  are  round,  oval,  or  elliptical  bodies, 
from  1  /*  in  diameter  to  5-6  fi  long  and  2-3  /u,  in  breadth,  the  largest 
exceeding  greatly  the  tubercle  bacillus  in  size.  They  stain  deeply  with 
carboi-fuchsin  but  decolorize  by  Gram's  method.  They  are  found  in 
tuberculous  tissues,  especially  glands,  quite  frequently,  and  are  believed 
to  be  involution  forms  of  the  tubercle  bacillus.  Walsham  states  that 
they  are  sometimes  seen  in  pure  cultures  of  the  tubercle  bacillus. 

Staining. — The  tubercle  bacillus  stains  with  difficulty,  owing  to  the 
large  amount  of  fatty  or  waxy  matter  it  contains  (ten  to  forty  per 
cent),  but  having  once  taken  the  stain,  resists  decolorization  strongly, 
a  characteristic  which  enables  one  to  distinguish  it  readily  from  the 
vast  majority  of  other  bacteria.  In  the  examination  of  sputum  one 
can  usually  be  safe  in  depending  entirely  on  this  characteristic,  but 
when  examining  feces  and  urine  or  certain  tissues,  further  precautions 
must  be  taken  which  will  be  spoken  of  later. 

Various  stains  have  been  proposed  for  demonstrating  the  tubercle 
bacillus,  but  the  great  superiority  of  the  Ziehl-Neelsen  carboi-fuchsin 
stain  over  all  others  has  led  to  its  practically  universal  adoption. 

Saturated  alcoholic  solution  of  fuclisiii 11  c.c. 

Solution  carbolic  acid  in  water  (five  per  cent).  .    100  c.c. 


16  ETIOLOGY— THE  TUBERCLE   BACILLUS 

In  practice  a  .small  portion  of  the  material  to  be  examined — sputum, 
pus,  scraping  of  tissue,  cultures,  etc. — is  spread  evenly  and  thinly  on  a 
cover-glass  or  slide  and  dried  in  the  air.  Next  the  glass  is  passed 
through  an  alcohol  or  Bunsen  flame  three  times  with  about  the  speed 
one  waves  the  hand  to  a  friend,  the  film  side  being  uppermost.  This 
"fixes"'  the  material.  Sufficient  stain  is  used  to  entirely  cover  the 
film  and  heat  is  a|)plied  until  steam  arises.  This  is  ke|)t  up  for  three 
to  live  minutes;  the  preparation  is  then  washed  in  water  and  decolor- 
ized until  it  becomes  a  faint  pink.  In  doing  this  it  is  alternately  put 
in  the  decolorizer  and  washed  in  clear  water.  The  preparation  nuiy 
then  be  counterstainod  with  methylene  blue,  washed,  and  examined  wet, 
or  else  dried  and  mounted  in  cedar  oil  or  balsam.  The  examination  is 
preferably  made  without  a  counterstain,  especially  if  the  tubercle  bacilli 
are  few  in  number,  since  the  deeply  stained  rods  stand  out  very  clearly 
in  the  practically  unstained  field,  and  can  scarcely  escape  detection. 

For  decolorization  sulphuric  and  nitric  acids  are  the  best,  and  liave 
been  used  in  various  strengths  up  to  thirty-three  per  cent,  though  the 
stronger  solutions  are  now  seldom  employed.  The  most  satisfactory 
solution  for  decolorization  in  the  writer's  experience  consists  of 

Nitric  acid  (concentrated) 5  parts. 

Alcohol    (eighty  per  cent) 1)5       " 

A  very  convenient  method  for  the  practitioner  is  that  of  Gabbett, 
in  which  the  decolorizer  is  combined  with  the  counterstain.  The  film 
is  stained  with  carbol-fuchsin,  as  described  above,  washed  and  flooded 
Avith  Gabbett's  solution,  which  should  be  left  on  cold  for  thirty  to 
forty-five  seconds,  and  then  washed  off  in  an  abundance  of  water.  Gab- 
bett's  solution  consists  of 

Methylene  blue   3  parts. 

Sulphuric   acid    25       " 

Water   75       " 

Ehrlich's  anilin-water  stain  is  still  preferred  for  some  purposes.  Its 
great  disadvantage  is  that  it  decomposes  rapidly,  while  the  carbol-fuch- 
sin may  be  kept  indefinitely.  It  is  prepared  as  follows:  To  100  c.c.  of 
water  add  5  c.c.  anilin  oil.  shake  well,  then  pass  through  a  moistened 
filler.  To  the  filtrate  add  drop  by  drop  a  saturated  alcoholic  solution 
of  ini'lliyl  violet,  or  fuchsin,  until  a  metallic  luster  a])pears  on  the  sur- 
face. According  to  Weigert,  11  c.c.  of  tlie  stain  is  added  to  100  c.c. 
of  the  anilin  watei'.  The  tubercle  bacillus  retains  the  stain  when 
treated  with  Gram's  iodin  solution. 


STAINING  17 

In  ccrtaiu  lesions,  and  especially  in  pus  from  old  abscesses  and 
sputum,  it  is  often  impossible  to  demonstrate  tubercle  bacilli,  though 
inoculation  of  these  tissues  will  produce  tuberculosis.  It  has  been 
believed  by  some  that  the  tubercle  bacillus  formed  spores  in  the  tissues 
Avhich  could  not  be  demonstrated,  but  accounted  for  the  pathogenicity 
of  these  lesions. 

In  lilOO  Marniorck  demonstrated  the  fact  that  young  tubercle 
bacilli  lost  their  stain  when  treated  with  acid — in  other  words,  were 
not  acid-fast — tliis  characteristic  being  acquired  with  age  and  depend- 
ing on  the  formation  of  fatty  material. 

E.  Klebs  ("04)  published  confirmatory  and  more  extensive  obser- 
vations. He  describes  three  stages  in  the  development  of  the  tubercle 
bacillus  seen  in  cultures  on  liquid  media  called  "  veil,"  "  white  layer,"' 
and  "  yellow  masses."  In  the  two  first  no  rods  can  be  demonstrated 
by  the  usual  fuchsin-acid  method.  Stained  with  methylene  blue,  fine 
particles,  among  which  are  rods  and  granules,  may  be  seen.  Granules 
are  seen  in  great  numbers  in  the  •'  veil,"  while  rods  are  more  numer- 
ous in  the  "  white  layer  "  and  stand  closer  to  the  tubercle  bacillus. 

Much  ('07)  investigated  the  subject,  and  by  the  use  of  a  modi- 
fication of  Gram's  stain  demonstrated  two  forms  of  the  tubercle  bacillus 
which  are  not  acid-fast.  One  resembles  the  ordinary  form  morpho- 
logically, while  the  other  consists  of  granules  which  may  occur  singly, 
in  groups,  or  connected  so  as  to  form  little  rods.  They  are  usually 
associated  with  the  rod  forms,  which  appear  to  be  the  intermediate 
stage  between  the  granular  and  acid-fast  rods.  ]\Iichaelides  has  con- 
firmed these  findings,  and  describes  a  form  of  the  tubercle  bacillus 
which  is  negative  to  Gram  as  well  as  to  Ziehl-Xeelsen,  but  takes  tbe 
Loffler-Giemsa  stain. 

Herman  has  for  many  years  employed  the  following  method  for 
staining  the  tubercle  bacillus  in  sputum,  pus,  or  in  tissues.  Stain : 
Crystal  violet,  three-per-cent  solution  in  ninety-five  per  cent  alcohol. 
Mordant :  Carbonate  of  ammonia,  one  per  cent  in  distilled  water. 
These  solutions  are  kept  in  separate  bottles  and  mixed  just  before  use 
in  the  proportion  of  one  part  of  the  stain  to  three  parts  of  the  mordant. 
The  slide,  covered  with  the  stain,  is  heated  on  a  water  bath  until  vapor 
rises  for  one  minute.  It  is  then  decolorized  in  nitric  acid  (ten  per  cent) 
for  a  few  seconds,  and  next  in  ninety-five  per  cent  alcohol,  after  which 
it  is  well  washed  in  water.  Iv)siii  (one  per  cent)  makes  a  good  counter- 
slain  if  it  is  wisbcd.  Merman  showed  in  ISS!)  tlial  tubercle  bacilli  conid 
be  demonstrated  in  tissues  bv  Ibis  method  when  otlieis  failed,  lie  lias 
recently  compared  it  willi  Die  ]>rocess  recommended  l)y  Much,  and 
believes  if  distinctly  superior.  Not  only  does  it  reveal  a  greater  num- 
ber of  l)acilli  in   a   <iiven   tissue,  but    where   none  cmii    be  demonstrated 


18  ETIOLOGY— THE  TUBERCLE   BACILLUS 

by  carbol-fuchsin,  and  only  granular  forms  by  the  method  of  Mueh, 
this  stain  shows  whole  rods. 

Pontes  has  recently  ('09)  made  studies  concerning  the  fat  and  waxy 
substances  in  the  tubercle  bacilli  and  their  relation  to  staining.  He 
finds  marked  differences  in  this  respect  between  pseudo  and  real  tubercle 
bacilli.  The  pseudo  tubercle  bacilli  vary  greatly  in  their  resistance  to 
decolorization,  and  this  is  modified  by  age  of  the  culture.  Of  ten  strains, 
each  showed  difference  in  acid  resistance.  The  following  fluid  is  rec- 
ommended as  a  decolorizer  for  ordinary  work  in  staining  tubercle  bacilli : 
absolute  alcohol,  one  part;  acetic  acid,  two  parts.  After  decolorization 
with  this  fluid,  if  one  then  stains  by  Gram's  method,  the  pseudo  tubercle 
bacilli  give  an  intensive  positive  result  and  show  thick  granulations. 
True  tubercle  bacilli  retain  the  red  stain  Avliile  the  intensive  Gram  posi- 
tive granulations  appear  to  be  separated  from  one  another.  In  general 
practice  the  following  stain  is  recommended  for  the  differentiation  of 
tubercle  bacilli  from  the  pseudo  bacilli:  (a)  stain  preparation  with 
Ziehl's  carbol-fuchsin ;  (b)  wash  in  tap  water;  (c)  stain  for  about  two 
minutes  with  carbol  crystal  violet;  (d)  treat  with  Lugol  solution  until 
no  more  metallic  mirrors  are  formed,  then  treat  with  acetone  alcohol 
(equal  parts  of  acetone  and  alcohol)  ;  (e)  wash  in  tap  Avater;  (/)  stain 
with  methylene  blue.  After  this  treatment  the  tubercle  bacilli  show  red, 
with  violet-colored  granulations  separated  from  each  other.  The  pseudo 
tubercle  bacilli  are  stained  violet,  without  the  red  border,  and  show  thick 
granulations.  The  granulations  are  usually  one  to  six  in  number,  some- 
times eight  to  ten.  If  only  one  is  seen  it  occupies  the  center  of  the 
bacillus.  It  seems  that  even  if  the  granulation  form  is  not  a  character- 
istic resistance  form,  at  least  it  is  the  most  resistant  form  of  the  tubercle 
bacillus  known  to  us. 

Experiments  made  with  this  method  in  the  writer's  laboratory  seem 
to  substantiate  Pontes'  claims. 

Staining  in  Tissues. — The  tissue  is  preferably  embedded  in  paraffin, 
which  permits  the  cutting  of  very  thin  sections.  The  sections  are  pre- 
pared and  mounted  on  slides  in  the  usual  way.  (1)  Stain  lightly  in 
alum-hematoxylin.  (2)  Wash.  (3)  Stain  with  carbol-fuchsin,  five  to 
six  minutes  hot  or  twenty  to  thirty  minutes  cold.  (4)  Wash.  (5) 
Decolorize  in  acid  alcohol.  (6)  Wash  thoroughly.  (7)  Wash  in  alco- 
hol (ninety-five  per  cent)  until  carbol-fuchsin  is  removed.  (8)  xVnilin 
oil,  2  parts;  xylol,  1  part.  (9)  Xylol  until  clear.  (10)  Mount  in  xylol 
balsam. 

The  staining  reactions  of  the  tubercle  bacillus  were  for  a  long  time 
considered  diagnostic.  Koch  found  only  the  bacillus  of  leprosy  which 
might  be  confounded  with  the  tubercle  bacillus,  but  the  differentiation 
is  not  difficult.     The  lepra  bacillus  takes  the  stain  much  more  easily 


OTHER  ACID-FAST   BACILLI-PSEUDO-TUBERCLE   BACILLI       19 

than  the  tubercle  bacillus,  coloring  in  cold  aqueous  solutions  of  the 
anilin  dyes  in  a  few  minutes.  Its  grouping,  packed  densely  witliin  the 
cells,  is  also  characteristic. 

Of  much  more  practical  importance  is  the  differentiation  of  the 
smegma  bacillus,  especially  in  the  examination  of  urine,  since  more 
than  once  has  the  diagnosis  of  genito-urinary  tuberculosis  been  made 
and  operative  procedures  resorted  to  through  mistaking  this  organism 
for  the  tubercle  bacillus.  The  smegma  bacillus  is  commonly  found 
about  the  corona  glandis  in  man  and  the  interlabial  folds  in  woman; 
also  in  the  inguinal  fold,  the  scrotum,  etc.,  hence  it  is  apt  to  be  found 
in  specimens  of  urine  collected  in  the  usual  way. 

Griinbaum  found  the  smegma  bacillus  in  fifty-nine  per  cent  of 
urines  from  women,  but  rarely  in  urine  from  men.  Samples  of  urine 
should  be  drawn  with  a  sterile  catheter  inserted  only  after  careful  cleans- 
ing of  the  meatus  and  adjacent  parts. 

Various  methods  of  differential  staining  have  been  devised,  the  most 
reliable  of  which  is  that  of  Bunge  and  Trantenroth.  It  depends  on  the 
fact  that  after  immersion  in  alcohol,  or  alcohol  and  ether,  the  smegma 
bacillus  loses  its  resistance  to  decolorizing  agents,  while  the  tubercle 
bacillus  under  the  same  treatment  retains  it.  According  to  Dahms, 
who  has  made  a  careful  study  of  the  question,  the  method  is  absolutely 
reliable.  It  is  carried  out  as  follows:  (1)  Place  the  spread  cover-glass, 
without  previous  heating,  into  absolute  alcohol  for  three  hours.  (2) 
Treat  with  a  three-per-cent  chromic-acid  solution  for  fifteen  minutes. 
(3)  Stain  with  carbol-fuchsin.  (4)  Treat  with  concentrated  alcoholic 
solution  of  metliylene  blue  for  five  minutes.  The  smegma  bacillus  will 
be  stained  blue,  the  tubercle  bacillus  red.  Dahms  says  that  the  smegma 
bacillus  never  shows  the.  curved  forms  so  often  seen  in  the  tubercle 
bacillus.  Sudan  III  is  also  very  reliable  for  differentiation,  the  only 
drawback  being  that  occasionally  true  tubercle  bacilli  stain  very  faintly 
with  it. 

Other  Acid-Fast  Bacilli — Pseudo-Tubercle  Bacilli. — The  researches 
of  the  past  few  years  have  brought  to  light  a  considerable  number  of 
organisms  which  have  the  power  of  resisting  decolorization  by  the 
mineral  acids.  Owing  to  this  peculiarity,  they  are  spoken  of  as  the 
"  acid-fast  "  group.  They  have  been  found  under  widely  varying  con- 
ditions and  may  lead  to  confusion.  Moeller  has  isolated  them  from 
timothy  hav,  the  feces  of  animals,  and  human  sputum.  They  have 
l)C(ii  foiiiid  in  nasal  mucus  (Karlinski),  gangrene  of  the  lung  (Rabi- 
uowitsch,  Beneiiuti,  Ophiils).  chronic  bronchopneumonia  (Birt  and 
Leishmau),  catarrhal  bronchitis  (Lichtenstein),  milk  and  butter  (Petri, 
Rabinowitsch,  Korn,  Kayserling,  etc.).  earth,  seeds,  hay.  dung,  etc., 
so  it  must  be  concluded  ibat  Ihev  liavc  a  wide  distribution  in  nature. 


20  ETIOLOGY— THE  TUBERCLE   BACILLUS 

The  organisms  of  this  group  are  readily  differentiated  from  the 
tubercle  bacillus  by  their  rapid  growth  in  culture,  their  ability  to  grow 
at  temperatures  unsuitable  to  the  tubercle  bacillus,  and  their  feeble 
pathogenicity.  Some  of  them  are  strongly  chromogenic.  Moeller  sug- 
gests the  following  method  of  differentiation :  Add  the  suspected  mate- 
rial to  bouillon  aifd  incubate  at  30°  C.  for  several  days.  If  rapid  mul- 
tiplication of  the  acid-fast  organisms  takes  place,  we  have  to  deal  with 
the  pseudo-tubercle  bacillus. 

The  relation  of  the  pseudo-tubercle  bacillus  group  to  the  true  organ- 
ism has  not  been  determined.  It  is  supposed  by  some  that  a  close 
relationship  exists  between  the  two,  but  this  has  not  been  proved. 
Koch,  however,  found  that  the  serum  of  animals  which  had  received 
injections  of  attenuated  tubercle  bacilli  would  agglutinate  the  bacilli 
of  avian  and  fish  tuberculosis,  the  hay  and  the  butter  bacillus;  and 
conversely  animals  treated  with  the  pseudo-bacillus  yielded  serum  which 
agglutinated  the  true  tubercle  bacillus. 

Inoculation  of  small  animals  with  the  grass  and  butter  bacilli  pro- 
duces localized  and  nonprogressive  lesions,  though  the  nodules  resemble 
tubercles.  They  are  more  prone  to  undergo  softening  and  suppuration, 
however.  Death  is  produced  only  when  large  quantities  are  injected. 
Infected  animals  do  not  respond  to  the  tuberculin  test. 

Cultures  may  be  obtained  on  ordinary  culture  media  in  from  twenty- 
four  to  forty-eight  hours — a  sure  method  of  differentiation  from  the 
tubercle  bacillus. 

Diagnosis  of  Tuberculosis  by  Microscopic  Examination. — A  ques- 
tion naturally  arises  as  to  the  effect  of  the  discovery  of  this  acid-fast 
group  on  the  value  of  microscopic  findings  in  the  examination  of  spu- 
tum, etc.  In  the  examination  'of  urine,  feces,  milk,  etc.,  the  microscopic 
examination  should  be  controlled  by  animal  inoculations.  Although 
acid-fast  bacilli  have  been  found  in  bronchitis,  gangrene  of  the  lung, 
and  the  nasal  secretions,  such  findings  are  unusual,  and  with  the  excep- 
tion of  leprosy  there  is  no  evidence  that  any  bacilli  which  possess  the 
staining  peculiarities  and  morphology  of  the  tubercle  bacillus  are  found 
in  the  human  body  with  any  degree  of  frequency.  There  is  in  addition 
an  overwhelming  mass  of  evidence  regarding  the  clinical  value  of  the 
examination  of  sputum  and  other  morbid  products.  While  the  possi- 
bility of  error,  due  to  other  acid-fast  bacilli,  should  always  be  borne  in 
mind  and  guarded  against,  we  are  nevertheless  warranted  in  placing 
a  high  degree  of  confidence"  in  the  routine  microscopic  examination  as 
described. 

Cultivation  of  the  Tubercle  Bacillus. — The  tubercle  bacillus  is  one 
of  the  most  strict  parasites  known,  and  its  cultivation,  especially  in 
the  first  generations,  is  attended  with  some  difficulty.     It  requires  par- 


CULTIVATION   OF   THE  TUBERCLE   BACILLUS  21 

ticiilai'ly  ail  I'Vcn  aiid  exact  Icinpcraf  iirc.  )iicrcral)Iy  slightly  higher 
than  that  of  the  blood. 

Koch  first  succeedpd  in  obtaining  eultiires  fni  coagulafed  blooH 
serum.  Nocard  soon  after  found  that  the  addition  of  peptone,  salt, 
and  cane  sugar  made  a  better  medium,  and  kiter  still  Nocard  and  Roux 
demonstrated  the  value  of  glycerin,  which  is  now  uni%ersally  added  to 
culture  media  and  for  which  no  substitute  has  been  found.  It  is  most 
often  added  in  the  proportion  of  live  per  cent. 

The  isolation  of  cultures  is  l)est  carried  out  by  the  method  of  Theo- 
bald Smith.  The  medium  used  is  dog's  serum,  obtained  by  bleeding 
in  a  thoroughly  aseptic  manner,  so  that  the  serum  requires  no  sterili- 
zation. It  is  put  into  tubes  having  a  ground-glass  cap,  with  a  small 
tubulation  connecting  with  the  air,  plugged  with  glass  wool.  These 
tubes  are  slanted  in  a  suitable  oven,  and  the  serum  is  coagulated  at  a 
temperature  of  76°  C.  The  addition  of  five  per  cent  gh'cerin  improves 
the  serum.  The  material  from  which  the  culture  is  to  be  isolated  is 
inoculated  into  a  guinea  pig,  which  is  killed  after  the  disease  is  devel- 
oped— usually  about  three  weeks. 

The  animal  is  opened  carefully  with  sterile  instruments,  and  por- 
tions of  the  omentum,  spleen,  liver,  or  glands  are  removed  to  a  Petri 
dish.  These  are  cut  into  small  portions,  which  are  transferred  to  the 
surface  of  the  prepared  serum.  No  attempt  at  breaking  up  the  pieces 
or  rubbing  them  over  the  surface  must  be  made.  The  tubes  are  placed 
in  an  incubator  and  inclined.  The  atmosphere  of  the  incubator  is 
kept  saturated  with  moisture  by  a  large  dish  of  water.  After  about 
three  weeks  the  pieces  of  tissues  are  crushed  with  a  stout  platinum 
needle  or  glass  rod,  rubbed  over*  the  surface  of  the  serum,  and  the  tubes 
returned  to  the  incubator.  A  week  or  ten  days  later  colonies  may  gen- 
erally be  seen  with  the  naked  eye. 

Human  cultures  not  infrequently  grow  luxuriantly  in  the  first  gen- 
eration, and  can  almost  always  be  transferred  at  once  to  glycerin-agar. 
Bovine  cultures,  on  the  other  hand,  generally  give  an  exceedingly  scanty 
growth  for  several  generations,  giving  to  the  surface  of  the  serum  the 
appearance  of  ground  glass,  as  first  pointed  out  by  Smith.  If  subcul- 
tures are  made  on  glycerin-agar  at  this  stage,  one  often  fails  to  obtain 
any  growth,  and  at  best  it  is  very  scant.  It  requires  a  number  of 
generations  of  artificial  cultivation  before  a  luxuriant  growth  takes 
place. 

Dorset  has  shown  that  the  tubercle  bacillus  grows  readily  on  hen's 
eggs,  and  that  this  medium  is  a  most  favorable  one  for  the  isolation 
of  cultures,  growth  taking  place  more  rapidly  than  on  blood  serum.  It 
is  prepared  as  follows:  Eggs,  not  more  than  a  week  old,  are  carefully 
broken  into  a  sterile  flask  and  gentlv  shaken  to  mix  the  yolk  with  the 


22  ETIOLOGY— THE   TUBERCLE    BACILLIS 

white  without  the  formation  of  hubljles.  When  the  niixiug  is  com- 
plete it  is  put  into  tubes,  slanted  in  a  blood-serum  oven,  and  coagu- 
lated at  70°  to  74°  C.  This  usually  requires  four  to  five  hours  on  two 
successive  days,  sterilization  being  accomplished  at  the  same  time.  Be- 
fore inoculation  a  few  drops  of  sterile  water  are  added  to  insure  moisture. 
Cultures  of  the  human  bacillus  may  l)e  obtained  directly  from  spu- 
tum on  Hesse's  medium.     Formida: 

Niihrstoff  Heyden ii  gms. 

Sodium  chlorid   5     " 

Agar 10     " 

Glycerin   30  c.c. 

Solution  carbonate  sodium  (crystals)   28. G  per 

cent 5     " 

Water    1,000     " 

Sputum  rich  in  tubercle  bacilli  is  selected,  and  a  small  clump  is  thor- 
oughly washed  by  passing  it  successively  through  five  or  more  dishes 
containing  sterile  normal  salt  solution.  It  is  then  transferred  to  a  dish 
containing  solidified  Hesse's  agar  and  drawTi  over  the  surface.  The 
plates  are  incubated  in  a  moist  chamber,  colonies  making  their  appear- 
ance in  four  to  six  days. 

De  Schweinitz  and  Dorset,  from  the  large  amount  of  phosphorus 
found  in  the  ash  of  tubercle  bacilli,  concluded  that  a  salt  of  phosphorus 
would  be  a  desirable  addition  to  culture  media  for  the  tubercle  bacillus. 
Tests  of  various  salts  showed  that  the  acid  potassium  phosphate  gave 
the  best  results.  At  the  Biochemic  Division  of  the  Bureau  of  Animal 
Industry  in  Washington  the  following  formula  is  used  for  the  growth 
of  large  quantities  of  tubercle  bacilli  for  the  manufacture  of  tuberculin : 
To  one  part  of  freshly  chopped  meat  add  two  parts  of  distilled  water. 
Keep  the  mixture  at  45°  to  58°  C.  for  three  hours;  strain,  boil,  and 
filter.  Add  Witte's  peptone,  one  per  cent ;  acid  potassium  phosphate, 
one  half  per  cent.  Bring  reaction  to  one  per  cent  acid  to  phenolphtha- 
lein.  Boil  one  hour,  filter,  and  add  glycerin  (seven  per  cent).  Examine 
reaction  and  adjust  to  one  per  cent  acid,  if  necessary. 

Homogeneous  Cultures. — The  tubercle  bacillus  in  ordinary  cultures 
grows  only  on  the  surface  of  the  medium,  where  it  has  free  access  to 
air.  On  bouillon  it  forms  a  thick,  wrinkled  pellicle  over  the  entire 
surface,  extending  a  certain  distance  up  the  sides  of  the  containing 
flask,  the  bouillon  below  remaining  entirely  clear.  In  making  such 
cultures  a  small  piece  of  pellicle  is  carefully  floated  on  the  surface.  If 
this  becomes  disturbed  and  sinks,  no  growth  takes  place.  Arloing  and 
Courmont  have  shown   that  certain  cultures  mav  he  ti*ained   to  grow 


BIOLOGY    OF   TUBERCLE   BACILLUS  23 

uniformly  through  the  liuid.  To  aecouipiisli  this  the  cultures  are  .shaken 
daily.  Such  cultures  are  called  "  homogeneous,"  and  are  used  for  deter- 
mining the  agglutinating  power  of  the  hlood.  Homogeneous  cultures 
are  dithcult  to  produce,  but  subcultures  grow  readily  and  retain  their 
characteristic  growth  indefinitely. 

Having  once  accustomed  the  tubercle  bacillus  to  growth  under  arti- 
ficial conditions,  luxuriant  cultures  are  obtained  without  ditliculty.  The 
media  commonly  employed  are  agar-agar  and  bouillon,  to  which  five 
per  cent  glycerin  has  been  added,  and  ])otato  soaked  in  a  five-per-cent 
aqueous  solution  of  glycerin. 

When  large  quantities  of  tubercle  bacilli  are  needed,  as  in  the  manu- 
facture of  old  tuberculin,  glycerin-bouillon  in  flasks  which  give  a  large 
surface  is  generally  emploj-ed,  as  the  growth  takes  place  only  on  the 
surface  of  the  culture  medium  where  the  access  of  air  is  free. 

Biology  of  Tubercle  Bacillus. — The  tubercle  bacillus  is  a  nonmotile, 
aerobic  and  facultative  anaeroljic  organism.  It  is  a  strict  parasite, 
not  having  a  habitat  outside  the  bodies  of  man  and  animals.  It  belongs 
to  the  higher  bacteria,  standing  intermediate  between  the  true  bacteria 
and  the  higher  fungi  known  as  hyphomyces.  It  appears  to  be  closely 
related  to  the  actinomyces,  occasionally  forming  clusters  much  like  the 
"  Driisen  "  of  this  fungus. 

For  artificial  cultivation  it  requires  a  temperature  about  that  of 
human  blood.  The  optimum  temperature  is  slightly  higher  than  this 
38°  to  38.5°  C.  The  limits  between  which  growth  will  take  place 
are  30°  to  42°  C.  for  mammalian,  25°  to  45°  C.  for  avian  cultures. 
Cultures  which  have  been  grown  for  a  long  time  on  artificial  media 
become  less  susceptible  to  differences  in  temperature.  Sander,  after 
prolonged  cultivation,  reports  having  obtained  growth  on  glycerin- 
potato  broth  at  22°  to  23°  C. 

The  discovery  of  tuberculosis  in  carp,  traced  to  the  deposit  of 
human  sputum  in  the  pond  in  which  they  were  reared,  and  the  devel- 
opment of  the  slowworm  bacillus  by  Moeller,  indicate  that  the  tubercle 
bacillus  can  become  accustomed  to  temperatures  at  Avhich  it  ordinarily 
refuses  to  grow.  Cultures  from  fish  and  the  slowworm  grow  at  room 
temperature,  and  will  not  grow  at  body  heat.  However,  the  tubercle 
bacillus  does  not  find  in  nature  conditions  suitable  for  its  development, 
and  there  is  no  evidence  that  it  has  a  habitat  outside  of  the  living  body. 
The  vast  numbers  thrown  out  in  sputum,  dejecta,  and  other  pathologic 
materials,  do  not  reproduce  their  kind,  and  meet  a  more  or  less  speedy 
death  through  the  action  of  drying,  light,  putrefaction,  and  such  agen- 
cies. Unfortunately,  they  survive  a  sufficient  time  to  gain  entrance  to 
the  bodies  of  other  men  and  animals,  where  favora])le  soil  for  growth 
may  be  found,  and  thus  the  vicious  circle  is  kept  up. 


24  ETIOLOGY— THE  TUBERCLE   BACILLI'S 

Spore  Formation. — The  unstained  areas  or  vacuoles  so  often  seen 
in  the  hacilli  are  supposed  hy  some  observers  to  l)e  evidence  of  spore 
formation.  By  others  the  deeply  stained  points  are  believed  to  he  spores. 
The  fact  that  tuberculosis  can  be  produced  in  animals  by  the  inoculation 
of  caseous  matter  in  which  tubercle  bacilli  are  not  readily  found  under 
the  microscope  has  also  led  to  belief  in  the  formation  of  spores.  It  is 
impossible  to  speak  positively  on  the  matter,  but  the  evidence  against 
spore  formation  is  very  strong.  The  resistance  of  the  tubercle  bacillus 
to  destructive  agents,  while  in  some  respects  greater  than  commonly 
found  in  nonspore-bearing  bacteria,  is  not  nearly  equal  to  that  of  true 
spores.  Furthermore,  the  occurrence  of  a  number  of  these  areas  in  a 
single  bacillus  is  strongly  against  their  being  spores. 

Resistance. — When  thoroughly  dry,  tubercle  bacilli  can  survive  a 
temperature  of  100°  C.  for  one  hour  (Muir  and  Ritchie).  If  moist, 
they  are  usually  killed  after  one  hour  at  70°  C.  Theobald  Smith  has 
shown  that  when  suspended  in  distilled  water,  normal  salt  solution, 
milk,  or  bouillon,  and  care  is  taken  to  insure  even  heating,  the  bacilli 
are  killed  in  from  fifteen  to  twenty  minutes  at  00°  C,  the  majority 
being  destroyed  in  five  to  ten  minutes.  In  milk  the  pellicle  which  forms 
when  heated  to  66°  C.  may  contain  living  bacilli  after  one  hour,  hence 
the  ordinary  home  pasteurization  of  milk  may  fail  to  destroy  all  tubercle 
bacilli.  Russell  and  Bang  have  confirmed  these  results.  Cold  has  prac- 
tically no  destructive  effect  on  the  tubercle  bacillus.  It  retains  its 
virulence  intact  for  as  long  as  six  weeks,  exposed  to  cold  at  times  as 
low  as  10°   C.  below  zero   (Cornet). 

Light,  both  direct  sunlight  and  diffused,  rapidly  kills  the  tubercle 
bacillus.  Jousset  found  that  tuberculous  sputum  was  certainly  sterilized 
after  forty-eight  hours'  exposure  to  either  direct  or  difl'used  sunlight. 
Twitchell  found  that  sputum  was  incapable  of  producing  a  lesion  after 
seven  hours'  exposure  to  direct  sunlight,  which  corresponds  closely  with 
Koch's  original  observation  that  the. tubercle  bacillus  was  killed  by 
exposure  to  direct  sunlight  in  a  few  minutes  to  several  hours,  according 
to  the  thickness  of  the  layer  exposed. 

Drying. — Koch  found  that  sputum  dried  at  the  temperature  of  the 
laboratory  was  virulent  for  guinea  pigs  after  eight  weeks.  Schill  and 
Fischer  found  that  when  quickly  dried,  sputum  retained  its  virulence 
for  four  months;  after  seven  months  its  virulence  was  lost.  Twitchell 
found  that  sputum  kept  on  a  handkerchief,  a  woolen  blanket,  and  on 
wood  at  room  conditions  produced  lesions  in  guinea  pigs  after  seventy 
days,  but  not  after  one  hundred  and  ten  days.  Sputum  on  a  carpet 
caused  lesions  after  thirty-nine  days,  but  not  after  seventy  days. 

Decomposition. — Widely  differing  results  have  been  obtained  Ijy  dif- 
ferent experimenters,  but  it  may  be  stated  positively  that  the  tubercle 


BJOLOdY    OF   TTBERCLE   BACILLUS  25 

bacillus  is  not  as  rapidly  destroyed  bv  decomposition  as  other  patho- 
genic organisms.  A^irulent  bacilli  were  found  by  Twitchell  in  sputum 
kept  in  a  sealed  bottle  placed  in  a  moist,  dark  box,  after  one  hundred 
and  seventy  days,  but  not  after  one  hundred  and  eighty-eight  davs. 
Other  observers  state  that  decomposition  diminishes  the  virulence  of 
tuberculous  material  rapidly,  and  that  it  is  sometimes  entirely  destroyed 
within  a  few  days   (Falk,  Baumgarten,  Fischer,  quoted  by  Cornet). 

Tuberculous  tissues  retain  their  virulence  after  burial  in  the  soil  for 
a  long  time.  Cadeac  and  Malet  obtained  positive  results  by  the  inocu- 
lation of  lung  buried  for  one  hundred  and  sixty-seven  days.  Petri 
found  that  the  tissues  of  a  tuberculous  rabbit  remained  virulent  for 
three  znonths  and  six  days  when  buried  in  a  zinc  box.  but  for  only  one 
month  and  five  days  when  a  wooden  box  was  used.  Galtier  found  that 
tuberculous  tissues  immersed  in  water  renewed  from  time  to  time  re- 
mained virulent  for  two  months.  Chantemesse  and  Widal  found  cul- 
tures alive  after  immersion  for  seventy  days  in  sterilized  Seine  water, 
though  virulence  was  lost.  Sawizky  subjected  sputum  to  conditions 
such  as  ordinarily  found  on  the  floors  of  dwellings,  and  found  that  it 
retained  its  virulence  for  two  to  two  and  a  half  months. 

In  general  it  can  be  said  that  darkness  and  moisture  favor  retention 
of  life  and  virulence  in  the  tubercle  bacillus,  but  it  must  be  borne  in 
mind  that  rapid  drying  also  preserves  vitality  for  long  periods  of  time. 
This  condition  is  fulfilled  in  the  usual  bedroom  by  the  small  particles 
of  sputum  thrown  out  during  sneezing  and  coughing. 

Chemicals. — The  tubercle  bacillus  in  pure  cultures  is  killed  by  a 
five-per-cent  solution  of  carbolic  acid  in  thirty  seconds ;  by  a  one-per- 
cent solution  in  one  minute.  Cctrrosive  sublimate  (1-1,000)  destroys 
it  in  ten  minutes.  Many  other  chemicals,  such  as  trikresol  (one  per 
cent),  lysol  (two  per  cent),  formalin,  etc.,  rapidly  destroy  its  vitality. 
Unfortunately,  the  disinfection  of  morbid  products,  especially  sputum, 
is  a  much  more  difficult  matter,  yet  in  the  daily  life  of  the  physician 
this  is  the  prol)lem  which  confronts  him.  Carbolic  acid  (five-per-cent 
solution),  added  to  an  equal  volume  of  sputum,  will  disinfect  in  twenty- 
four  hours  if  the  mixture  is  stirred.  Weaker  solutions  require  much 
longer  time. 

For  the  disinfection  of  sputum  Rosenau  advises  formalin  (fifteen 
to  twenty  per  cent),  trikresol  (two  per  cent),  or  lysol  (two  per  cent). 
At  least  an  equal  volume  of  the  disinfecting  solution  must  be  added 
to  the  sputum,  thoroughly  mixed,  and  allowed  to  stand  two  hours. 
Corrosive  sulilimato  is  not  a  good  disinfectant  for  sputum,  owing  to 
the  coagulation  which  lakes  place.  Some  other  chemicals  are  efficient, 
l)ut  their  cost  puis  them  out  of  the  range  of  usefulness  for  practical 
purposes. 


26 


ETIOLOGY— THE  TUBERCLE   BACILLUS 


Chemical  Composition  of  the  Tubercle  Bacillus. — The  first  chemical 
analysis  of  tubercle  bacilli  was  made  by  Hammerschlag,  who  obtained 
his  material  from  agar  and  broth  cultures.  More  extensive  analyses 
on  larger  amounts  of  bacilli  have  been  made  by  de  Schweinitz  and  Dor- 
set, E.  Klebs,  Euppel,  Aronson,  Levene,  von  Behring,  Romer  and  Rup- 
pel,  and  others.  The  chemical  composition  varies  greatly  according  to 
the  media  on  which  the  cultures  are  grown,  as  shown  by  de  Schweinitz 
and  Levene. 

Analyses  of  Tubercle  Bacilli.  » 
DE  Schweinitz  and  Dorset. 


Dried  at 

100°  C. 

Ash-free. 

Cultures  on  Broth. 

Cultures  on 
Asparagin  Syn- 
thetic Media. 

Cultures  on  Broth. 

Cultures  on  Syn- 
thetic Media, 
Asparagin. 

c 

61.55  per  cent. 
8.59    "       " 
7.55    "       " 
0.44    "       " 
0.82    "       " 
4.03    "       " 

62.16  per  cent. 
9.19    " 
8.94    "       " 
0.22    "       " 
0.66    "       " 
1.92    "       " 

63.33  per  cent. 
8.88    "       " 
7.74    "       " 
0.45    "       " 

63.35  per  cent. 
9.36    "       " 
9.14    "       " 
0.23    "       " 

H 

N 

S 

P 

Ash 

Hammerschlag. 

Levene. 

Cultures  on  Agar 
and  Broth. 

Cultures  on  Broth. 

Cultures  on  Man- 

nite.  Synthetic 

Media. 

Alcohol  and  ether  extract 27.02  per  cent. 

C 51.62    "       " 

H 8.07    "       " 

N 9.09    "       " 

S 

31.56  per  cent. 

55.58  "  " 
8.46  "  " 
9.39  "  " 
1.39  "  " 
0.59  "  " 
5.92    "       " 

22.18  per  cent. 

47.41  "  " 
7.05  "  " 
7.91  "  " 
0  25    "       •' 

P 

2  67    "       " 

Ash 8.00    "       " 

10.00    "       " 

Analyses  of  Tubercle  Bacilh,  shoaving  Organic  Constituents. 


Hammer- 
schlag. 

DE  Schweinitz  and  Dorset. 

RUPPEL. 

Dried  at  100°  C. 

ASH-FREE. 

Broth. 

Asparagin. 

Broth. 

Asparagin. 

Broth. 

Fat 

Proteid  

Carbohydrate,  or 
other  residue 

Ash 

27.2% 
26.9% 

28.1% 
8.0% 

42.33%o 
46.34% 

7.16% 
2.90% 

42.01% 
55.87% 

7.46% 
1.92% 

43.90% 
48.10% 

4.75% 

42.87% 
57.12% 

4.84% 

23.5% 

31.7% 

44.8%, 

» Tables  taken  from  article  by  Dr.  E.  R.  Baldwin  in  Nothnagel's  Encyclopedia. 


CHEMICAL    COMPOSITION    OF   THE   TUBERCLE   BACILLUS        27 

Asli. — Analysis  of  the  ash  from  glycerin-bouillon  cultures  of  feebly 
virulent  bacilli  by  de  Schweinitz  and  Dorset  gave  the  following : 

NaoO    13.62  per  cent. 

KJ)    6.35 

CaO    12.64 

MgO    11.55 

SiO 0.57 

P.O,    55.23 

In  a  later  series  of  determinations  made  on  cultures  from  several  sources 
and  groMTi  on  media  containing  0.5  per  cent  acid  potassium  phosphate, 
they  found  the  P2O5  varied  as  follows :  Bovine  bacilli,  58.04  per  cent ; 
swine  bacilli,  56.48  per  cent;  horse  bacilli,  55.40  per  cent;  avian  bacilli, 
55.63  per  cent;  attenuated  human  bacilli,  74.38  per  cent;  virulent 
human  bacilli,  60.90  per  cent.  The  amount  of  phosphorus  varies  directly 
with  the  amount  of  fat  in  general. 

Fats. — The  tubercle  bacillus  is  unique  in  having  the  largest  amount 
of  fatty  or  waxy  matter  of  any  known  micro-organism.  It  almost  cer- 
tainly owes  its  ability  to  resist  injurious  agents  to  these  substances, 
and  as  first  shown  by  Klebs  its  peculiar  staining  reactions  are  due  to 
the  same  cause.  The  fat  is  difficult  to  extract  entirely,  and  is  made 
up  of  a  number  of  substances  whose  nature  has  not  yet  been  satisfac- 
torily determined.  The  amount  of  fat  is  influenced  greatly  by  the 
composition  of  tlie  culture  medium,  and  especially  the  amount  of 
gl3'cerin  employed.  Euppel  found  that  the  fat  content  varied  with  the 
age  of  the  cultures  from  8  to  10  per  cent  up  to  25  to  26  per  cent. 

According  to  the  culture  and  method  employed,  the  following  per- 
centages of  fat  have  been  obtained :  Hammerschlag,  26.2  per  cent ; 
Klebs,  22  per  cent;  de  Schweinitz  and  Dorset,  37  to  42  per  cent;  Aron- 
son,  20  to  25  per  cent;  Euppel,  8  to  10  per  cent  to  25  to  26  per  cent; 
Kresling,  25  to  40  per  cent. 

De  Schweinitz  and  Dorset  believed  the  fat  to  be  made  up  of  the 
fatty  acids — palmitic,  arachidic,  and  possibly  lauric.  Ruppel  extracted 
three  kinds  of  fat  from  the  tubercle  bacillus:  (1)  By  cold  alcohol,  a 
greasy  red  material  containing  free  fatty  acids  and  a  residue  melting 
at  55°  to  60°  C,  and  readily  saponified;  (2)  by  hot  alcohol,  a  colorless 
waxy  matter  melting  at  65°  C.  probably  the  fatty  acid-esters  of  some 
higher  alcohols  (palmitic  and  stearic)  ;  (3)  by  ether,  a  wax,  melting  at 
65°  to  70°  C,  proba])ly  containing  the  fatty  acid-esters  of  ceryl  and 
triyricil  alcohols. 

Kresling  obtained  the  largest  amount  ol*  fat  from  the  tubercle  bacil- 
lus by  extra(ttion  with  chloroform   (35  to  36  per  cent),  next  by  benzol 


28  ETIOLOGY— THE  TUBERCLE   BACILLUS 

(34.31  per  cent),  then  by  ether  (30.75  per  cent),  and  alcohol  (24.76 
per  cent).  He  found  the  fatty  matter  to  be  made  up  of  free  fatty 
acids  (14.38  per  cent),  neutral  fat,  and  fatty  acid-esters  (77.25  per 
cent.  He  considers  the  composition  of  the  fat  of  the  tubercle  bacillus 
as  peculiar  to  itself.  De  Schweinitz  and  Dorset  determined  the  fat  in 
a  number  of  different  cultures  by  ether,  alcohol,  and  chloroform  extrac- 
tion, with  the  following  results:  Bovine  bacilli,  26.32  per  cent;  swine 
bacilli,  20.59  per  cent;  horse  bacilli,  31.76  per  cent;  avian  bacilli,  30.65 
per  cent ;  virulent  human  bacilli,  28.03  per  cent ;  attenuated  human 
bacilli,  37.41  per  cent.    All  cultures  were  grown  on  the  same  medium. 

Levene  studied  only  the  waxy  substance.  He  found  that  benzol  and 
toluol  were  the  best  solvents.  The  melting  point  Avas  55°  to  60°  C, 
and  it  contained  C,  66.62  per  cent;  H,  11.30  per  cent;  0,  22.08  per 
cent. 

Proteids. — Hammerschlag  first  recognized  proteid  in  the  residue  of 
the  tubercle  bacillus  after  extraction  with  alcohol  and  ether.  Levene, 
from  cultures  grown  on  s^mthetic  media,  extracted  three  proteid  sub- 
stances which  coagulated  respectively  at  56°  to  64°  C.  72°  to  75°  C, 
and  94°  to  95°  C.  The  first  substance  was  precipitated  by  magnesium 
sulphate  (fifty  to  eighty-five  per  cent)  and  by  saturation  with  common 
salt,  the  second  by  saturation  with  magnesium  sulphate,  and  the  third 
by  saturation  with  ammonium  sulphate.  All  three  contained  phos- 
phorus, the  greatest  amount  being  found  in  the  third.  The  same  three 
substances  were  found  in  an  ammonium  chlorid  extract  of  beef-broth 
cultures.  Xo  ordinary  albumin  was  found,  the  body  substance  being 
made  up  chiefly  of  nucleo-proteids.  The  study  of  the  extracts  gave 
no  evidence  of  the  formation  by  the  tubercle  bacillus  of  true  toxal- 
bumins,  analogous  to  those  found  in  some  other  pathogenic  organisms. 

Carbohydrates. — Hammerschlag  and  de  Schweinitz  and  Dorset  ob- 
tained reactions  showing  the  presence  of  carbohydrates  in  cultures  of 
tubercle  bacilli,  which  the  former  believed  to  be  due  to  cellulose. 
Levene  isolated  from  both  broth  and  mannite  cultures  a  glycogenlike 
substance  which  does  not  reduce  Fehling's  solution,  but  acquired  the 
reducing  power  on  being  heated  with  mineral  acids.  It  was  obtained 
from  the  sodium  chlorid  and  ammonium  chlorid  extracts,  and  also  from 
the  residue  after  extraction.  It  contained  only  traces  of  nitrogen 
and  phosphorus,  and  gave  with  iodin  a  color  test  similar  to  that  of 
glycogen. 

Poisons  of  the  Tubercle  Bacillus. — The  poisons  formed  by  the  tuber- 
cle i^acillus  are  complex  in  character  and  not  well  understood.  The 
original  tvherrvlin  of  Koch  contained  a  number  of  substances,  among 
which  were  proteids  resistant  to  heat  and  closely  allied  to  the  albu- 
moses.    It  is  doubtful  if  it  contained  any  true  toxin.    Analysis  of  tuber- 


POISONS   OF   THE  TUBERCLE   BACILLUS  29 

culiii  ;<li()\vs  lliat  it  contains  prott'ids  whieli  diilVr  fi'om  any  known 
albumoses  or  toxalbumins  by  their  power  to  resist  heat.  Klebs  and 
Hunter  found  alkaloids,  but  Kiihne  failed  to  detect  them.  He  found 
an  albuminate,  a  peculiar  (aero)  albumose^  deutero-albuniose,  traces  of 
peptone,  and  tryptophan,  a  digestive  product.  The  active  principle  of 
tuberculin  has  been  shown  to  be  in  the  nucleo-proteids  and  their  deriva- 
tives. Baldwin  and  Levene  recognized  that  the  active  principle  existed 
in  crude  tuberculin  in  combination  with  a  proteid. 

Euppel,  who  made  a  thorough  study  of  the  poisons  of  the  tubercle 
bacillus,  found  the  filtrate  from  cultures  to  be  entirely  non-specific,  and 
to  contain  no  toxic  substance  except  albumoses.  He  failed  also  to  iso- 
late any  specific  poison  from  the  bacilli  by  extraction.  From  crushed 
bacilli,  however,  he  isolated  two  poisonous  substances — tuhercuUnic  acid, 
a  nucleic  acid  containing  9.42  per  cent  of  phosphorus,  and  a  protamine 
which  he  called  tuberculosamine. 

Tuberculin ic  acid  is  the  most  poisonous  substance  yet  isolated  from 
the  tubercle  bacillus,  being  three  and  a  half  to  four  times  as  strong  as 
dry  old  tuberculin.  From  tuberculinic  acid  Ruppel  and  Kitishima  pre- 
pared tuherculothymic  acid  and  a  still  more  poisonous  substance,  which 
was  isolated  in  crystalline  form,  called  tuherculosine.  It  is  twent3^-five 
to  thirty  times  as  poisonous  as  old  tuberculin,  and  is  believed  by  Behring 
to  be  the  poison  nucleus,  without  which  the  specific  tuberculin  reaction 
cannot  take  place.  Euppel  considers  these  substances  as  derivatives  of 
the  cell  nucleus. 

Levene  has  analyzed  tuberculinic  acid  obtained  from  the  extracts 
of  tubercle  bacilli  and  also  from  the  nucleo-proteid.  The  average  com- 
position was:  C,  33.66  per  cent;'H,  5.83  per  cent;  N,  9.63  per  cent; 
P,  11.33  per  cent.  He  found  that  the  composition  of  various  samples 
obtained  by  him  varied  greatly.  He  isolated  from  tuberculinic  acid 
thymin  and  cystosin. 

In  1897  de  Schweinitz  and  Dorset  isolated  from  cultures  of  tubercle 
bacillus  on  liquid  medium  a  crystalline  substance  soluble  in  ether,  alco- 
hol, and  water,  which  had  a  necrotic  effect  on  the  liver  when  injected 
into  guinea  pigs.  They  identified  it  as  ternconic  acid,  an  unsaturated 
acid  of  the  fatty  series. 

Of  the  substances  which  have  been  isolated  from  the  tubercle  bacil- 
lus so  far,  the  nucleo-proteid  and  its  derivatives  produce  the  most 
marked  effects.  Tuberculous  animals  give  typical  tuberculin  reactions, 
local  and  general,  following  injections  of  these  products,  and  death  is 
caused  hj  very  small  doses. 

Toxin  Formation. — Xo  one  has  yet  demonstrated  the  formation  by 
the  tubercle  bacillus  of  true  toxin,  and  it  is  doubtful  if  it  produces  one. 
It  has  been  shown  that  none  of  the  poisons  so  far  isolated  are  toxins, 


30  ETIOLOGY— THE   TUBERCLE    BACILLUS 

aud  the  analysis  of  Levene  proved  the  absence  of  joxalbuniins  fnuii  ex- 
tracts of  the  bacillus.  Poisonous  substances  have  been  found  in  the 
blood  and  urine  of  consumptives  and  in  tuberculous  tissues  of  animals, 
but  their  nature  has  not  been  proven. 

Baldwin  believes  that  the  symptoms  and  toxemia  of  tuberculosis  are 
fairly  accounted  for  by  the  presence  of  the  nucleic  acid  products  in 
the  blood,  and  that  tlie  intimate  combination  between  the  mulcin  and 
wax,  which  is  so  resistant  to  absorption,  explains  tubercle  formation  and 
the  slow  poisoning. 

Preparation  of  Tuberculin. — The  original  tuberculin  of  Koch  was 
prepared  by  growing  tubercle  bacilli  on  bouillon  made  from  fresh  veal, 
to  which  was  added  dried  peptone  (one  per  cent),  sodium  chlorid  (one 
half  of  one  per  cent),  glycerin  (five  per  cent).  When  full  growth  had 
taken  place  (six  to  eight  weeks)  the  cultures  were  poured  out  into  an 
evaporating  dish,  placed  on  a  water  bath,  and  evaporated  to  one  tenth 
of  the  original  volume.  The  remains  of  the  bacteria  were  tben  removed 
by  filtration.  The  resulting  licjuid  contained  fifty  per  cent  of  glycerin 
and  was  very  stable.  The  process  has  been  modified  in  various  ways, 
the  object  being  the  same — to  make  a  hot  glycerin  extract  of  the  intra- 
cellular poisons  of  the  tubercle  bacillus.  At  the  laboratory  of  the  State 
Livestock  Sanitary  Board  of  Pennsylvania,  where  large  quantities  of 
tuberculin  are  made  for  use  in  cattle,  the  fully  grown  cultures  without 
being  opened  are  placed  in  a  steam  sterilizer  and  kept  in  streaming 
steam  for  five  to  six  hours.  The  bacteria  are  removed  by  filtration 
through  paper,  and  the  filtrate  concentrated  on  a  water  bath  to  one 
tenth  of  the  original  volume.  Before  use  it  is  diluted  with  a  one  half 
of  one  per  cent  solution  of  carbolic  acid  and  passed  through  a  Berkefelt 
filter. 

Numerous  attempts  have  been  made  by  Koch,  E.  Klebs,  and  others 
to  purify  tuberculin.  The  addition  of  alcohol  to  tuberculin  throws  down 
a  white  flocculent  powder  which  may  be  further  purified  by  washing 
with  alcohol.  It  is  soluble  in  water  and  contains  the  active  principles 
of  tuberculin. 

Klebs's  antiphthisin  and  tnberculocidin  are  well-known  representa- 
tives of  such  products.  In  the  preparation  of  tuberculocidin,  cultures 
on  liquid  media  are  allowed  to  macerate  in  the  incubator  for  several 
months  in  order  to  extract  the  intracellular  substances,  and  then  precipi- 
tated with  sodium-bismuth-iodid  and  alcohol. 

Maragliano  prepares  a  tuberculin  by  extracting  the  bodies  of  the 
bacilli  with  distilled  water.  The  cultures  are  filtered,  the  bacilli  washed, 
and  macerated  over  a  water  bath  at  85°  C.  for  six  days.  The  culture 
medium  does  not  enter  into  the  preparation. 

The  watery  extract  of  Von  Ruck  is  similar  to  the  above.    The  washed 


SOURCES   OF    INFECTION  31 

Itacilli  aiv,  however,  treated  wjtli  alcohol  and  ether,  pulverized,  and  then 
extracted  with  water  at  50°  C.  for  a  longer  period. 

Tvberculol  (Landmann)  is  prepared  hy  making  normal  saline  and 
glycerin  extracts  of  pulverized  tubercle  bacilli  at  40°,  50°,  and  100°  C, 
which  are  then  combined  and  evaporated  at  37°  C,  to  small  volume. 

The  new  tuherculinfi  of  Koch  are  prepared  from  the  bodies  of  viru- 
lent ])acilli.  T.  A.  (Tuberculin  Alkaline)  is  made  by  digesting  bacilli 
with  a  one  tenth  normal  solution  of  caustic  soda,  then  filtering.  T.  0. 
(Tuberculin  Oberst)  and  T.  R.  (Tuberculin  Rest)  are  prepared  by  trit- 
urating thoroughly  tubercle  bacilli  which  have  been  previously  dried. 
Distilled  water  is  added  and  the  whole  mixture  put  in  a  centrifugal 
machine.  The  top  layer  is  removed  and  called  T.  0.  The  sediment 
is  again  dried,  triturated,  water  added  and  centrifugalized,  the  operation 
being  repeated  until  no  residue  is  left.  The  product  is  called  T.  R. 
Bacillen  Emulsion  (R.  E.)  is  Koch's  most  recent  modification.  It  con- 
sists of  finely  pulverized  virulent  tubercle  bacilli  suspended  in  equal 
parts  of  water  and  glycerin. 

Beraneck's  tuberculin  is  made  from  cultures  grown  on  bouillon  con- 
taining no  peptone.  The  bacilli  are  taken  out  by  filtration  and  extracted 
with  a  ten-per-cent  solution  of  orthophosphoric  acid.  The  filtrate  is 
evaporated  to  one  tenth  of  its  volume  in  vacuo  and  precipitated  with 
alcohol,  the  precipitate  and  extract  being  then  mixed  in  equal  parts. 

The  Perlsuclit  tuberculin  of  Spengler  is  Koch's  old  tuberculin  made 
from  bovine  cultures. 

Yon  Behring  has  recently  put  out  several  products  of  the  tubercle 
bacillus,  more  or  less  allied  to  tuberculin,  definite  descriptions  of  which 
are  difficult  to  obtain.  Tuherculqse  is  an  emulsion  of  the  residue  of 
tubercle  bacilli  after  being  extracted  successively  with  alcohol,  water, 
ten-per-cent  solution  of  sodium  chlorid,  and  other  substances.  The 
bacilli  are  further  subjected  to  treatment  with  chloral  hydrate.  The 
use  of  tuberculase  is  restricted  to  cattle. 

Tulase  is  used  for  man  as  well  as  animals.  It  is  a  clear,  yellowish 
fluid,  said  to  contain  all  the  constituents  of  the  tubercle  bacillus. 

Tulaselactin  is  a  preparation  of  tulase  in  the  form  of  a  milky  emul- 
sion. When  fresh  it  is  said  to  have  but  slight  tuberculin-reacting  prop- 
erties, but  acquires  them  later  through  instability. 

Various  other  preparations  have  been  announced  from  time  to  time, 
all  of  which  contain  the  same  principle  in  greater  or  less  quantity  and 
more  or  less  modified  by  the  process  of  extraction. 

Sources  of  Infection. — It  has  already  been  said  tluit  the  tubercle 
l)acillus  is  a  strict  parasite,  and  is  not  found  outside  of  the  animal 
body,  except  in  places  contaminated  by  morbid  products  of  man  and 
animals. 


32  ETIOLOGY— THE  TUBERCLE   BACILLUS 

Mail  is  the  chief  source  of  danger  for  man,  and  the  sputum  of  the 
consumptive  plays  the  most  important  part  in  the  dissemination  of  the 
bacilli.  Nuttall  has  estimated  from  a  series  of  counts  that  a  fairly 
well  advanced  consumptive  spits  out  from  one  and  a  half  to  four  and 
a  third  billion  bacilli  in  twenty-four  hours.  It  is  evident  that  a  single 
consumptive  who  is  careless  in  his  habits  may  be  the  means  of  endan- 
gering many  people.  The  bacilli  deposited  on  the  streets  in  sputum  soon 
lose  their  vitality  through  the  action  of  light,  air,  etc.,  and  the  danger 
from  this  source  has,  no  doubt,  been  exaggerated,  though  it  must  be 
recognized  and  guarded  against.  Sputum  unquestionably  retains  its 
virulence  for  a  longer  time  in  dark  and  moist  places,  such  as  may  be 
found  in  public  conveyances,  houses,  etc.  Rooms  which  have  been  occu- 
pied by  consumptives  may  retain  virulent  bacilli  for  at  least  six  weeks 
(Cornet).  Cornet  believes  that  a  consumptive  infects  only  a  small 
area  about  him — 30  to  50  cubic  meters. 

It  is  generally  believed  that  the  distribution  of  bacilli  takes  place 
through  the  dr.ying  and  pulverization  of  sputum,  which  is  then  easily 
carried  as  dust  by  currents  of  air  and  inhaled  or  swallowed.  Fliigge 
considers  the  fine  particles  or  droplets  of  sputum  ejected  during 
coughing,  sneezing,  and  speaking  as  the  chief  source  of  infection. 
He  found  that  an  artificial  spray  remained  suspended  in  the  air 
for  as  much  as  five  hours.  It  has  been  shown  by  other  observers,  experi- 
menting by  placing  the  Bacillus  prodigiosus  in  the  mouth,  that  during 
speaking  and  coughing  the  droplets  were  sent  as  much  as  4  meters  from 
the  mouth,  and  by  stronger  currents  of  air  even  30  meters.  Heyraann, 
employing  an  artificial  spray  of  tubercle  bacilli,  found  that  the  droplets 
remained  suspended  in  the  air  for  one  and  a  half  hours  at  most.  He 
found  that  after  falling  to  the  floor  the  bacilli  usually  soon  died.  He 
obtained  a  fair  number  of  positive  results  on  the  second  and  third 
days,  and  occasionally  on  the  twelfth  and  even  eighteenth  days.  It  is 
impossible  at  present  to  estimate  correctly  the  relative  importance  of 
these  two  sources  of  infection.  Both  must  be  recognized  and  guarded 
against. 

Sputum  is  also  disseminated  through  the  habit  of  spitting  into  hand- 
kerchiefs, which  soil  the  pocket  into  which  they  are  placed.  Drying  and 
pulverization  take  place  rapidly.  Hands  soiled  with  sputum  also  help 
in  the  spread  of  infection.  Baldwin  has  shown  that  living  tubercle 
bacilli  are  not  infrequently  present  on  the  hands  of  tuberculous  persons 
who  are  not  careful  in  their  habits.  Kissing  must  also  be  mentioned 
as  a  possible  source  of  infection. 

The  relation  of  bovine  tuberculosis  to  human  health  has  been  the 
subject  of  much  discussion,  and  is  referred  to  elsewhere.  It  has  been 
proved  that  the  bovine  tubercle  bacillus  is  quite  frequently  found  in 


MODES  OF   INVASION  33 

Iho  lesions  of  eliildren,  and  the  bovine  disease  must  be  looked  on  as 
an  important  factor  in  the  causation  of  tuberculosis  in  man. 

Modes  of  Invasion. — Heredity. — The  portal  through  which  the 
tubercle  bacillus  gains  entrance  to  the  body  has  been  the  subject  of 
much  discussion  as  well  as  experimentation.  The  persistent  belief 
in  the  hereditary  nature  of  the  disease  has  for  a  long  time  done  much 
to  obscure  the  observations  of  professional  men  and  block  progress  in 
the  eradication  of  the  disease.  True  hereditary  tuberculosis  unques- 
tionably occurs,  but  in  a  minimum  number  of  cases.  A  careful  review 
of  the  literature  reveals  less  than  twenty-five  authentic  cases  in  man,  and 
while  in  cattle  a  much  larger  number  have  been  observed,  the  percentage 
is  still  very  low.  Experimentally  it  has  been  produced  through  the 
semen,  as  well  as  through  the  placental  circulation,  so  that  the  possi- 
bility must  be  admitted.  Eecent  studies  by  Warthin  and  Cowie  indi- 
cate that  placental  tuberculosis  is,  perhaps,  more  frequent  than  here- 
tofore believed.  If  this  is  true,  placental  transmission  is  probably  more 
frequent  than  it  is  now  considered  to  be. 

It  has,  however,  been  pointed  out  by  Schmorl  and  Ivockel,  who  made 
the  first  report  on  tuberculosis  of  the  placenta,  that  the  placental  villi 
have  a  remarkable  power  to  retain  their  integrity,  even  when  embedded 
in  tuberculous  new  growth.  When  the  villi  become  tuberculous,  throm- 
bosis Avith  occlusion  occurs,  as  is  the  rule  with  blood-vessels  elsewhere, 
and  the  supply  of  blood  is  cut  off.  Hence,  as  Cornet  justly  observes, 
the  presence  of  tubercle  bacilli  in  the  placenta  does  not  at  all  prove 
transmission  to  the  fetus.  Further  evidence  against  the  hereditary 
transmission  of  tuberculosis  in  man  is  found  in  the  statistics  of  orphan 
asylums.  As  is  well  knowTi.  tuberculosis  is  a  prime  factor  in  creating 
the  necessity  for  such  institutions,  yet  all  observers  are  practically  in 
accord  in  stating  that  tuberculosis  is  rare  among  these  children.  Demme 
has  observed  in  36,148  patients  in  children's  hospitals  1,932,  or  5.3  per 
cent,  with  tuberculosis.  Schnitzlein.  who  observed  613  children  in  an 
orphanage,  43.59  per  cent  of  whom  had  lost  one  parent,  and  6.86  per 
cent  both  parents,  from  tuberculosis,  reports  that  since  1876  not  a  single 
death  from  the  disease  has  taken  place. 

The  study  of  mortality  tables  from  all  sources  shows  that  tuber- 
culosis during  the  first  year  of  life  is  much  less  frequent  than  after 
this  period,  and  it  is  very  rare  during  the  first  few  months  of  life.  If 
infection  occurs  during  intra-uterine  life  we  would  certainly  find  the 
incidence  of  tuberculosis  during  the  first  few  months  of  life  greatly 
in  excess  of  what  statistics  show.  The  fact  must  be  emphasized  that 
children  born  of  tuberculous  parents,  when  removed  from  them  soon 
after  birth,  enjoy  a  freedom  from  the  disease  which  would  be  impossible 
if  intra-uterine  infection  was  not  extremely  uncommon.  Experience 
4 


34  ETIOLOGY— THE  TUBERCLE   BACILLUS 

with  cattle,  in  wliicli  iil(M-inc  tuljerciilosis  is  known  to  be  more  frequent 
than  in  the  human  race,  and  the  opportunity  for  hereditary  transmis- 
sion greater,  is  overwhehningly  in  favor  of  the  belief  that  postnatal 
infection  is  the  important  factor  to  be  guarded  against. 

What  is  known  as  the  Bang,  or  Danish  system,  which  has  proved 
after  years  of  trial  most  efficient,  is  based  on  this  fact.  Calves  born  of 
tuberculous  mothers  are  removed  at  once  to  barns  free  from  contagion 
and  reared  on  sterilized  milk  or  milk  from  healthy  cows.  The  results 
prove  that  even  in  cattle  intra-uterine  infection  is  rare.  It  may  be 
said  that  while  the  possibility  of  hereditary  transmission  of  tuberculosis 
must  be  admitted,  it  is  so  rare  as  to  l)e  practically  negligible  in  the 
consideration  of  modes  of  contagion,  and  hygienic  measures  designed 
to  combat  the  spread  of  the  disease. 

Woiitids,  etc. — A  similar  statement  may  be  made  in  regard  to  other 
modes  of  infection  which  are  sometimes  met  with  clinically  and  have 
experimentally  been  proved  possilile.  Among  these  may  be  mentioned 
accidental  inoculation  through  wounds,  the  eye,  the  ear,  and  the  genito- 
urinary organs.  Wound  infections  are  seen  most  often  in  those  doing 
autopsies  on  the  bodies  of  tuberculous  men  or  animals.  The  formation 
of  local  tubercles  at  the  site  of  inoculation  without  constitutional  dis- 
turbance usually  follows.  They  may  heal  under  protective  treatment, 
but  sometimes  require  excision.  There  are  on  record,  however,  a  cer- 
tain number  of  cases,  apparently  well  authenticated,  in  which  the  inva- 
sion went  farther,  causing  general  infection  with  involvement  of  the 
lungs  and  death.  The  reports  of  such  cases  must  be  studied  carefully, 
in  view  of  the  long  period  of  incubation  in  tuberculosis.  It  is  not 
easy  to  prove  that  the  wound  infection  was  the  cause  of  the  subsequent 
pulmonary  disease.  In  many  cases  it  is  probably  a  case  of  j^ost  hoc, 
not  propter  hoc.  Laennec,  who  died  of  phthisis,  attributed  his  dis- 
ease to  wound  infection,  hut  in  view  of  the  long  time  which  elapsed 
between  the  inoculation  and  his  death,  it  appears  that  he  was  mis- 
taken. 

Pulmonary  Tiiherculosis. — By  far  the  most  important  question  to 
1)e  considered  is  the  mode  of  invasion  in  pulmonary  tuberculosis.  The 
relation  of  the  lungs  to  the  external  air,  and  the  vast  preponderance  of 
pulmonary  tuberculosis  over  other  forms  of  the  disease,  naturally  led 
to  the  belief  that  infection  took  place  directly  through  the  respiratory 
tract.  This  idea  was  strengthened  by  observations  on  the  various  forms 
of  paeumonokoniosis  seen  in  those  whose  occupations  expose  them  to  the 
constant  breathing  of  air  laden  with  particles  of  foreign  matter. 

At  the  present  time  belief  in  the  respiratory  mode  of  entrance  is 
held  by  the  majority  of  the  medical  profession,  including  many  whose 
learning   entitles  their  opinion   to  high  consideration.      On   the  other 


MODES   OF   INVASION  35 

haud,  facts,  both  ('xjjcriiu<,'utal  ami  clinical,  are  constaullv  accunui- 
lating  which  prove  that  the  digestive  tract  is  an  important,  if  not  the 
most  important,  avenue  of  entry  for  the  tubercle  bacillus.  As  early 
as  1868  Chauveau  showed  that  infection  of  cattle  was  readily  produced 
by  feeding,  and  since  that  time  numerous  experimenters  have  obtained 
positive  results,  often  when  only  a  single  infected  meal  was  given. 

The  matter  was  brought  to  the  front  by  Koch,  in  his  London  ad- 
dress, 1901.  In  discussing  the  importance  of  bovine  tuberculosis  in 
relation  to  human  health,  he  took  the  ground  that  infection  through 
food  could  be  assumed  with  certainty  only  when  the  primary  lesion  was 
located  in  the  intestine,  and  on  the  claim  that  this  was  seldom  the 
case,  based  his  opinion  as  to  the  slight  importance  of  guarding  our  food 
products. 

In  considering  infection  through  the  digestive  tract,  a  question  at 
once  arises  as  to  the  correctness  of  the  premise  laid  down  by  Koch, 
which  assumes  that  the  tubercle  bacillus  cannot  enter  the  system  through 
the  intestinal  wall  without  the  production  of  a  lesion  at  the  point  of 
entrance.  It  leaves  out  of  consideration  the  possibility  of  infection 
through  any  other  part  of  the  alimentary  tract,  which  should  be  taken 
to  include  the  entire  apparatus  with  which  the  food  comes  in  contact, 
beginning  with  the  mouth. 

Mouth  and  Tongue,  Palate  and  Gums. — Tuberculosis  of  the  mouth, 
gums,  palate,  and  tongue  is  rare,  even  as  a  secondary  manifestation  in 
advanced  phthisis,  when  all  these  structures  are  constantly  exposed  to 
large  quantities  of  sputum  containing  myriads  of  tubercle  bacilli.  Ex- 
perimentally, infection  of  these  tissues,  with  enlargement  and  caseation 
of  the  related  glands,  is  fairl}^  easily  produced,  but  as  primary  avenues 
of  entrance,  under  natural  conditions,  they  play  an  insignificant  part. 

Tonsils. — The  same  cannot  be  said  of  the  tonsils,  which  are  not 
infrequently  the  seat  of  apparently  primary  tuberculosis,  and  constantly 
show  scars,  giant  cells,  and  other  changes  attril>utable  often  to  tubercu- 
losis. By  inoculation  of  guinea  pigs  Dieulafoy  found  tuberculosis  of  the 
tonsil  in  15  of  96  cases.  Latham,  who  was  careful  to  use  only  tlie 
interior  portions  of  the  tonsil,  in  45  consecutive  autopsies  on  children 
from  three  months  to  thirteen  years  of  age,  found  7  which  were  tulxn-- 
culous.  Confirmatory  results  have  been  obtained  by  Baup,  Friodniann, 
and  other  observers.  The  tonsils  are  very  frequently  tul)erculous  in 
persons  who  die  of  phthisis.  AValsham  found  tubercles  in  21  of  3-L  cases 
examined  ]»ost-mortem,  and  in  several  he  considered  the  lesion  primary. 
Tubercle  bacilli  may  be  lodged  in  the  tonsillar  crypts  and  remain  there 
a  longer  or  shorter  time  without  producing  tuberculosis  of  the  tonsil. 
The  results  of  Dieulafoy  have  been  severely  criticised  on  this  ground, 
and  properly  so,  since  he  made  no  histologic  examination  of  the  tissues 


36 


ETIOLOGY— THE  TUBERCLE   BACILLUS 


used  for  inoculation.     The  work  of  Latham,  with  practically  identical 
results,  is  not  open  to  a  similar  objection. 

The  tonsils  are  composed  of  lymphoid  tissue,  and  no  doubt  act,  to  a 
certain  extent,  like  lymph  glands  in  fdtering  out  and  retaining  invad- 
ing bacteria.  Hence,  while  they 
may  be  overwhelmed,  and  become 
avenues  of  entrance  for  the  tuber- 
cle l)acilhis,  they  certainly  prevent 
p^'stemic  infection  for  some  time. 
Their  ability  to  resist  tuberculous 
changes  is  remarkable. 

Experimentally,  the  suscepti- 
1)ility  of  the  tonsil  in  some  animals 
has  been  shown  repeatedly.  In  a 
series  of  experiments  at  the  labora- 
tory of  the  State  Livestock  San- 
itary Board  of  Pennsylvania  on 
the  comparative  virulence  of  hu- 
man and  bovine  tubercle  bacilli, 
swine  fed  with  jnire  cultures  in 
every  instance  developed  general- 
ized tuberculosis  with  marked  in- 
volvement of  the  tonsils,  which 
were  in  most  instances  necrotic  and 
ulcerated.  The  inspection  of  swine 
for  tuberculosis  by  the  United 
States  Government  is  based  on  the 
fact,  established  by  careful  observa- 
tion on  many  thousand  animals, 
that  the  lymph  glands  of  the  neck 
show  the  primary  lesion  in  the  vast 
majority  of  cases  (Figs.  1  and  3). 
Pharynx,  Esophagus. — Tubercu- 
losis of  the  pharynx  and  esophagus 
is  extremely  rare  under  any  circum- 
stances, and  as  a  primary  infection 
is  practically  unknown.  It  is  probable,  however,  that  the  intact  mucous 
membrane  of  the  pharynx  does,  at  times,  allow  the  passage  of  tubercle 
bacilli,  which  first  make  themselves  known  by  the  enlargement  of  the 
related  lymphatic  glands.  Experimental  evidence  of  this  is  very  strong, 
though  it  is,  of  course,  very  difficult  to  place  the  exact  point  of  entry. 
In  the  case  of  a  monkey  to  whom  the  writer  fed  tubercle  bacilli  on 
banana,  and  who  died  of  pulmonary  tuberculosis,  the  glands  of  the  neck 


r 

I 

Fig,  1.  —  Tongue  and  Tonsils  op 
Swine  Infected  by  Feeding  Tu- 
bercle Bacilli.  Extensive  ne- 
crosis of  tonsils,  which  apparently 
served  as  port  of  entry. 


MODES   OF   INVASION 


37 


were  enlarged  and  caseous,  and  no  lesion  of  the  tonsil  was  found,  so  it 
appeared  certain  that  invasion  had  taken  place  through  some  part  of 
the  mouth  or  pharynx.  The  habit  monkeys  have  of  storing  food  in  the 
lateral  pockets  of  the  mouth  renders  them  peculiarly  liable  to  infection 
through  the  mucous  membrane  of  this  region.  Cornet  has  also  pro- 
duced experimental  infection  through  the  uninjured  mucous  membrane 
of  the  ])harynx. 


Fig.  2. — Lungs  of  Swine  Infected  by  Feeding.     The  intestinal  tract  and  mesen- 
teric glands  free  from  lesions.     Infection  probably  through  tonsils.     See  Fig.  1. 

Stomach. — There  is  no  evidence  that  infection  ever  takes  place 
through  the  stomach.  Tuberculous  disease  of  the  stomach  is  one  of  the 
rarest  forms  met  with.  Tlie  cause  of  this  apparent  immunity  is  not 
evident,  but  is  attributed  by  some  to  the  hydrochloric  acid  of  the  gastric 


38  ETIOLOGY— THE  TUBERCLE   BACILLUS 

juice.  Nvinierous  experiments  have  been  made  to  determine  the  action 
of  the  gastric  juice  on  the  tubercle  bacillus  (Falk,  Wesener,  Strauss  and 
Wurtz,  Frank  and  Fischer,  Cadeac,  etc.),  both  artificial  and  natural 
juice  having  been  emi)loyed,  by  which  it  has  been  shown  that  the  tubercle 
bacillus  is  able  to  survive  intimate  contact  with  gastric  juice  for  at  least 
as  long  as  the  ordinary  digestive  period.  Clinical  experience  has  also 
proved  that  infection  of  the  intestine  through  swallowing  sputum  con- 
stantly takes  place  in  phthisis.  Further  proof  of  the  ability  of  the 
tubercle  bacillus  to  resist  for  some  hours  the  reaction  of  the  gastric 
juice  is  found  in  experiments  made  to  demonstrate  the  permeability  of 
the  intestinal  mucosa  (Dobroklonski,  Nicolas  and  Descos,  Eavenel,  Cal- 
mette,  etc.)  in  phthisis. 

Intestine. — The  frequency  of  intestinal  tuberculosis  in  phthisis  has 
just  been  mentioned.  The  autopsy  reports  of  various  pathologists  state 
that  it  is  found  in  from  thirty  to  ninety  per  cent  of  cases.  It  is  certain 
that  in  the  great  majority  of  these  the  actual  lesion  is  secondary,  and 
due  to  the  swallowing  of  sputum  laden  with  bacilli.  This  does  not, 
however,  in  any  way  preclude  the  possibility  that  the  pulmonary  disease 
was  caused  in  the  first  place  by  tubercle  bacilli  which  gained  access  to 
the  body  through  the  intestine.  In  other  words,  the  location  of  the 
primary  lesion,  on  which  so  much  stress  has  been  laid,  does  not  indicate 
with  certainty  the  point  of  entrance  of  the  invading  organism. 

In  regard  to  primary  intestinal  tuberculosis — that  is  to  say,  those 
cases  in  which  the  oldest  or  primary  lesion  is  found  in  the  intestine 
itself  or  in  the  related  glands — the  reports  from  pathologists  are  con- 
tradictory. This  is  probably  due,  in  part,  to  a  difference  in  methods  of 
examination  and  interpretation  of  results,  and  doubtless  also,  in  part, 
to  a  real  difference  in  the  incidence  of  such  cases  in  different  communi- 
ties, brought  about  by  local  customs  and  habits.  In  all  reports  a  con- 
siderable number  of  cases  are  found  in  which  it  has  been  impossible  to 
determine  the  site  of  the  primary  lesion.  It  is  very  difficult  to  draw 
entirely  correct  conclusions  from  many  of  the  reports,  since  they  have 
been  made  to  demonstrate  certain  points,  and  do  not  give  details  as  to 
other  important  features. 

In  England  the  pathologists  who  have  studied  tuberculosis  in  chil- 
dren are  practically  unanimous  in  considering  that  infection  frequently 
takes  place  through  the  intestinal  tract,  since  they  find  in  the  related 
glands  evidences  of  the  primary  lesion.  Still,  Symes  and  Fisher,  Shen- 
nan,  Guthrie,  Carr,  Ashby,  Batten,  Kingsford,  report  on  1,560  autopsies, 
in  which  the  primary  lesion  was  found  in  the  intestine  290  times,  or 
18.6  per  cent  of  all  cases. 

In  America,  Northrup,  Holt,  and  Bovaird  report  on  369  cases,  all 
in  New  York  or  its  environs,  with  5  of  intestinal  origin,  a  little  more 


MODES   OF   INVASION  39 

than  1  per  cent.  Holt  contributed  119  of  these  autopsies,  in  none  of 
which  did  he  consider  the  intestine  the  seat  of  the  primary  lesion.  It 
is  interesting  to  note,  however,  that  he  found  the  mesenteric  glands 
involved  in  35  per  cent  and  the  intestine  in  37  per  cent  of  these  cases. 

Hand  reports  from  the  Children's  Hospital  of  Philadelphia  115 
autopsies  on  tuberculous  children,  with  10  cases  (8.7  per  cent)  of  pri- 
mary intestinal  localization  and  1  of  tonsillar  invasion.  In  29  cases 
the  site  of  invasion  could  not  be  determined. 

In  this  connection  the  work  of  Councilman,  Mallory  and  Pearce  is 
most  instructive.  They  found  tuberculosis  in  35  of  220  children  dead 
of  diphtheria.  In  18  of  these  the  mesenteric  lymph  nodes  were  tuber- 
culous, with  involvement  of  the  intestine  6  times;  and  in  7  cases  the 
mesenteric  glands  were  diseased  without  involvement  of  any  other  part 
of  the  body.  In  13  cases  (37.1  per  cent)  the  infection  evidently  occurred 
through  the  digestive  tract. 

Statistics  from  Germany  are  most  confusing  and  contradictory. 
Baginsky,  in  5,448  autopsies  on  children,  1,468  of  whom  were  tubercu- 
lous, found  only  14  cases  of  primary  intestinal  involvement.  In  another 
series  of  806  autopsies,  144  of  which  were  tuberculous,  he  found  only  6 
in  which  he  considered  the  intestinal  lesion  to  be  the  oldest.  A  third 
series  of  figures  by  Baginsky,  often  quoted,  gives  the  results  of  933  cases 
of  tuberculosis  in  children,  in  which  he  never  found  intestinal  tuber- 
culosis without  involvement  of  the  lungs  and  bronchial  nodes.  These 
figures  are  without  value,  as  there  is  no  indication  of  the  site  of  the 
primary  infection. 

Biedert  found  only  16  cases  of  primary  intestinal  tuberculosis  in 
3,104  auto])sies  on  children.  Ganghofner,  Koch,  Heubner,  Benda,  von 
Hansemann,  and  others  agree  in  regarding  primary  intestinal  tubercu- 
losis as  comparatively  infrequent.  On  the  other  hand,  we  have  a  mass 
of  testimony  from  equally  reliable  observers  which  agrees  very  closely 
with  the  figures  from  England. 

Hueppe,  without  giving  statistics,  says  that  "the  number  of  cases 
(primary  intestinal  tuberculosis)  may  fairly  be  reckoned  as  between 
25  and  35  per  cent  of  all  deaths  in  children  from  tuberculosis."  Hof, 
in  a  systematic  study  of  the  autopsy  records  of  the  Pathological  Insti- 
tute at  Kiel,  found  2,697  cases  of  tuberculosis  in  adults,  159  (5.9  per 
cent)  of  which  were  primary  in  the  intestine,  while  in  84.9  per  cent 
the  respiratory  tract  was  primarily  involved.  In  children  there  were 
936  cases  of  tuberculosis,  235  (25.1  per  cent)  of  which  showed  evidences 
of  infection  through  the  intestine,  and  527  (56.2  per  cent)  resjuratory 
infection.  Wagener  (Kiel),  in  600  autopsies,  76  of  which  were  on  chil- 
dren, found  primary  intestinal  tuberculosis  in  16,  or  21.1  per  cent. 
Heller,  in  714  fatal  cases  of  di])htheria,  found  tuberculosis  140  times, 


40  ETIOLOGY— THE  TUBERCLE   BACILLUS 

in  53  (37.8  per  cent)  of  which  the  origin  was  ])rimary  in  tlie  intestine. 
In  a  later  series  of  230  autopsies,  Heller  found  intestinal  tuberculosis 
in  12  per  cent  of  adults  and  26  per  cent  of  children. 

Nebelthau,  in  26  autopsies  on  tuberculous  children,  at  the  Halle 
Polyclinic,  found  that  the  infection  was  primary  in  the  intestine  in  5 
(19.2  per  cent),  and  in  the  respiratory  tract  in  9  (34.6  per  cent),  while 
in  12  (46.1  per  cent)  both  tracts  were  infected.  Kossel,  in  14  children 
dead  of  other  diseases,  found  tuberculosis  of  the  bronchial  glands  10 
times,  and  of  the  mesenteric  glands  4  times.  In  22  children  who  died 
of  tuberculosis,  he  found  the  disease  confined  to  the  intestine  only  once. 
Lubarsch,  in  297  autopsies  on  children,  found  tuberculosis  in  63,  of 
which  14  (21.2  per  cent)  were  primary  in  the  alimentary  tract. 

Studies  on  the  bodies  of  children  who  died  of  other  diseases,  such 
as  those  reported  by  Councilman,  Mallory  and  Pearce,  Heller,  and  Kos- 
sel, are  particularly  valuable  in  the  determination  of  the  avenue  of 
entry  for  the  tubercle  bacillus.  It  is  well  known  that  in  children  tuber- 
culosis tends  to  become  generalized  rapidly,  and  at  autopsy  it  is  fre- 
quently impossible  to  tell  by  what  route  the  infection  took  place. 

When  death  has  come  from  other  causes,  the  tuberculous  lesion  is 
usually  localized,  and  often  confined  to  the  glands  which  are  in  relation 
to  the  point  of  invasion,  hence  the  portal  of  entry  can  be  determined 
with  great  certainty. 

In  a  most  masterly  study  Harbitz  gives  the  following  table  of  his 
own  results  obtained  from  117  cases: 

Primary  in  respiratory  tract 48  cases,  41  per  cent. 

Primary  in  digestive  tract 2G      "      22.0     " 

Primary  in  digestive  or  respiratory  tract. .  24      "      20.5     " 

General  lymph-node  tuberculosis 11      "        9.4     " 

Doubtful,  or  other  primary  seats 8      "        6.8     " 

For  the  sake  of  fairness,  statistics  have  been  given  at  some  length  in 
order  that  the  reader  may  know  the  ground  for  the  conclusions  arrived 
at  and  be  able  to  judge  of  their  soundness.  As  stated  before,  however, 
the  site  of  the  primary  lesion  does  not  always  indicate  the  point  of 
entrance  of  the  tubercle  bacillus,  and  this  is  probably  especially  true  of 
infection  by  way  of  the  intestine,  though  it  has  been  shown  by  numer- 
ous experimenters  (Cornet,  Dobroklonski,  Desoubry  and  Porcher,  Nico- 
las and  Descos,  Eomer,  Eenshaw,  Sidney  Martin,  Eavenel)  that  the 
mucous  membrane  of  the  various  parts  of  the  body  can  be  penetrated  by 
the  tubercle  bacillus  without  previous  injury  and  without  demonstrable 
lesion.  This  opinion  is  now  very  widely  held  by  pathologists,  owing  to 
the  extreme  frequency  with  which  various  groups  of  glands  are  found 


MODES   OF   INVASION 


41 


lo  be  tuberculous,  with  no  demoustrable  lesion  of  the  mucous  surface 
which  they  drain.     In  many  of  the  feeding  experiments  especial  care 


Fig.  3. 


Fig.  4. 


Figs.  3  and  4. — Tuberculosis  of  the  Intestines  and  Lungs  of  a  Monkey  Fed 
WITH  Tubercle  Bactlli.     (Probably  pulmonary  infection  through  intestines.) 


42  ETIOLOGY— THE   TUBERCLE    BACILLUS 

has  been  taken  to  avoid  injury  of  the  alimentaiy  tract,  the  bacilli  hav- 
ing been  mixed  witli  milk  given  on  baiianas,  etc.  Tn  some  experiments 
a  purge  of  castor  cnl  was  given  to  fiee  the  intestine  of  all  rough  matter 
it  might  have  contained,  and  the  animal  fed  on  soft  foods  for  a  num- 
ber of  days  before  the  infected  meal  was  given  (Figs.  3  and  4). 

Harbitz  considers  it  perfectly  reasonable  to  believe  tiiat  tubercle 
bacilli  may  pass  through  one  or  more  groups  of  lymph  nodes  before 
becoming  stationary  and  setting  up  inflammation,  supporting  this  view 
by  the  results  of  certain  feeding  experiments,  in  which  the  thoracic 
glands  have  been  found  to  be  tuberculous  without  corresponding  disease 
of  those  in  the  abdomen. 

Entrance  of  tubercle  bacilli  and  otlier  organisms  through  the  intes- 
tinal wall  without  demonstrable  lesion  has  been  proven  repeatedly,  jjegin- 
ning  with  the  work  of  Dobroklonski,  under  Cornil,  in  1890,  who  showed 
that  the  tubercle  bacillus  would  quickly  penetrate  the  healthy  wall  of  the 
intestine  in  guinea  pigs.  Desoubry  and  Porcher,  students  of  Nocard, 
showed  in  dogs  that  during  the  digestion  of  fats  large  numbers  of  bac- 
teria were  carried  through  the  intestinal  wall,  and  could  be  detected  in 
the  chyle.  If  food  deprived  of  fat  was  given,  few  or  even  no  bacteria 
were  found  in  the  chyle. 

In  feeding  experiments  conducted  at  the  laboratory  of  the  State 
Livestock  Sanitary  Board  of  Pennsylvania  we  often  observed  extensive 
tuberculosis  of  the  lungs  and  thoracic  glands  in  animals  which  showed 
slight  or  even  no  involvement  of  the  intestine.  In  1902-3,  acting  on 
the  suggestion  contained  in  the  work  of  Desoubry  and  Porcher,  the 
writer  introduced  into  the  stomachs  of  a  number  of  dogs  tubercle  bacilli 
suspended  in  an  emulsion  of  melted  butter  and  warm  water,  using  a 
stomach  tube  in  oider  to  avoid  possible  infection  through  the  trachea. 
The  dogs  were  killed  after  three  and  a  half  to  four  hours,  during  active 
digestion,  and  as  much  chyle  as  possible  collected,  together  with  the 
mesenteric  glands,  which  were  examined  microscopically,  and  also  inocu- 
lated into  guinea  pigs.  Tubercle  bacilli  were  demonstrated  in  abun- 
dance in  eight  out  of  ten  experiments,  proving  that,  during  the  diges- 
tion of  fat,  tubercle  bacilli  are  carried  rapidly  through  the  healthy 
intestinal  wall. 

Romer,  with  von  Behring,  has  shown  that  the  tubercle  bacillus,  and 
even  the  anthrax  bacillus,  which  is  very  much  larger,  passes  through 
the  normal  intestinal  mucosa  of  young  guinea  pigs  readily.  A  single 
feeding  with  a  minute  quantity  of  tubercle  bacilli  frequently  produced 
tuberculosis.  In  the  infected  animals  the  glands  of  the  neck  were  always 
involved,  and  later  there  often  developed  a  type  of  the  disease  usually 
regarded  as  the  expression  of  an  inhalation  tuberculosis.  Von  Behring 
asserts  that  the  origin  of  epidemiologic  pulmonary  tuberculosis  in  man, 


MODES   OF   INVASION  43 

*and  epizootic  pulmonary  tuberculosis  in  cattle,  is  a  prinuiry  intestinal 
infection  taking  place  in  early  infancy. 

The  subject  has  recently  been  studied  Ijy  Caluiette  and  his  fellow- 
workers  at  the  Pasteur  Institute  ol'  J^ille,  (iuerin,  Vansteenberghe,  and 
Grysez.  In  numerous  experiments  they  have  found  it  impossible  to 
produce  anthracosis  of  tlie  lungs  even  when  the  animals  were  compelled 
to  breathe  an  atmosphere  saturated  with  lampblack,  provided  the  esoph- 
agus was  closed.  On  the  other  hand,  when  lampblack  was  introduced 
into  the  stomach  by  means  of  a  tube,  or  mixed  with  food,  anthra- 
cosis of  the  lungs  appeared  rapidly.  When  tubercle  bacilli,  either  dry 
or  moist,  were  administered  l)y  inhalation,  by  intratracheal  insufflation, 
or  direct  inoculation  into  the  trachea,  the  bacilli  never  penetrated  far- 
tlier  than  the  first  branches  of  the  bronchi.  The  introduction  of  tubercle 
bacilli  into  the  stomach  througli  a  tulje,  in  order  to  avoid  all  danger  of 
respiratory  infection,  always  produced  tuberculosis  rajiidly. 

They  confirm  the  observation  that  tubercle  bacilli  readily  penetrate 
the  intestinal  wall  without  leaving  any  lesion.  They  have  traced  the 
bacilli,  and  found  that  as  soon  as  they  reach  the  chyle  vessels  they  are 
taken  up  by  leucocytes,  which  from  this  time  on  act  as  carriers,  and 
convey  them  to  the  related  gland,  where  they  are  retained  for  a  longer 
or  shorter  time,  reaching  finally  the  thoracic  duct,  which,  in  turn,  pours 
tliem  into  the  pulmonary  circulation.  They  are  then  arrested  in  the 
fine  capillaries  of  the  lung. 

If  the  leucocyte  has  taken  up  many  bacilli  it  soon  loses  its  motility 
and  acts  like  a  toxic  foreign  body,  against  which  the  cells  of  the  vessel 
wall  react,  and  englobement  by  one  of  the  cells  (endothelial  macro- 
phages) takes  place,  producing  the  primitive  tuliercle,  which  is  always 
intravascular.  On  the  other  hand,  leucocytes  which  have  englobed  only 
one  or  two  bacilli  retain  for  a  long  time  their  motility,  and  when  arrested 
in  the  capillaries  penetrate  the  vessel  walls  by  diapedesis,  reaching  the 
lymphatic  channels,  which  carry  them  to  the  bronchial  or  mediastinal 
glands.  Here  they  may  die,  and  the  contained  bacilli  produce  lesions; 
or  else  again  reach  the  thoracic  duct  and  the  circulation,  by  which  they 
are  carried  to  distant  parts  of  the  bod}^,  being  finally  killed  by  the 
poisons  of  the  bacilli  and  arrested  in  the  capillaries  of  some  organ  or 
tissue,  perhaps  the  meninges,  the  kidney,  the  joints,  etc.,  where  a  primi- 
tive tubercle  is  formed. 

In  young  animals  the  mesenteric  glands  retain  the  bacilli  and  the 
leucocytes  which  contain  them  for  some  time,  and  the  glands  enlarge  in 
proportion  to  the  intensity  of  the  infection,  the  lungs  becoming  sec- 
ondarily involved.  In  adult  animals,  on  the  contrary,  the  glands  do  not 
retain  the  bacilli  nearly  so  long,  and  they  can  be  found  in  the  lungs 
twenty-four  hours  after  their  introduction  into  the  stomach.     This  de- 


44  ETIOLOGY— THE  TUBERCLE   BACILLUS 

pends  oil  the  niimite  anatomy  of  tlic  glands,  which  arc  mucli  more 
permeable  in  adult  than  in  young  animals. 

Calmette  concludes  that  pulmonary  tuberculosis  acquired  at  any  age 
may  be  due  to  recent  intestinal  infection.  More  recently  Schlossmann 
and  Engel  have  shown  that  when  tubercle  bacilli  in  milk  or  cream  are 
injected  into  the  stomachs  of  young  guinea  pigs  through  an  incision  in 
the  abdominal  wall  they  reach  the  lung  in  a  few  hours,  as  proven  by 
killing  the  animal  and  inoculating  others  with  portions  of  the  lung. 

Eavenel  and  Eeichel  have  repeated  the  work  of  Schlossmann,  and 
have  obtained  confirmatory  results.  Fifty  guinea  pigs,  from  sixteen  hours 
to  two  weeks  old,  were  inoculated  directly  into  the  stomach.  They  were 
killed  from  four  to  twenty-four  hours  later,  and  their  lungs  inoculated 
into  other  guinea  pigs.  The  results  were  positive  in  28,  or  fifty-six  per 
cent,  the  larger  number  of  these  being  in  the  younger  animals.  Thirty 
of  these  pigs  were  killed  after  four,  five,  and  six  hours,  16  giving  posi- 
tive evidence  that  in  this  short  time  tubercle  bacilli  had  passed  from 
the  stomach  to  the  lungs  in  sufficient  numbers  to  produce  tuberculosis 
in  animals  inoculated  with  these  organs. 

Oberwarth  and  Eabinowitsch  have  given  conclusive  evidence  on  this 
matter,  employing  young  swane.  They  established  a  gastric  fistula  in 
these  animals,  and  then  closed  the  esophagus.  Tubercle  bacilli  intro- 
duced into  the  stomach  were  shown  to  have  reached  the  blood  and  the 
lungs  within  twenty-two  hours. 

Most  valuable  contributory  evidence  of  the  importance  of  infection 
through  the  digestive  tract  is  given  in  the  Second  Interim  Report  of 
the  Royal  (British)  Commission  on  Tuberculosis  (Part  1,  1!)07).  This 
commission,  appointed  to  study  the  relation  of  bovine  tuberculosis  to 
the  human  disease,  isolated  and  examined  60  cultures  of  tubercle  bacillus 
from  human  beings.  Fourteen  cultures  proved  to  be  the  bovine  bacillus 
— 1  obtained  from  sputum,  3  from  cervical  glands  removed  at  operation, 
and  10  from  the  lesions  of  primary  intestinal  tuberculosis  in  children. 
Similar  findings  have  been  reported  by  Ravenel.  de  Schweinitz,  Theobald 
Smith,  the  German  Commission  of  the  Imperial  Health  Office,  and  others. 

The  opportunities  for  the  inhalation  of  bovine  tubercle  bacilli  by 
human  beings  are  slight  at  best,  except,  perhaps,  for  persons  who  habitu- 
ally care  for  cattle,  and  compared  to  those  for  ingestion  they  are  insig- 
nificant. There  is  almost  no  possibility,  in  the  case  of  children,  for  the 
inhalation  of  bovine  bacilli,  even  if  we  admit  that  the  aspiration  of 
particles  of  food  may  occur.  We  are  therefore  forced  to  conclude  that 
in  those  cases  from  which  the  bovine  bacillus  has  been  isolated  the 
infection  has  taken  place  through  the  digestive  tract. 

Respiratory  Infection. — Experimental  demonstration  of  the  possibility 
of  infection  through  inhalation  w^as  first  given  by  Tappeiner  in  1877, 


MODES   OF    INVASION  45 

who  mado  dogs  breathe  air  hideii  with  dried  and  pulverized  sputum. 
In  later  experimcDts  by  Koch,  Cornet,  Gebhardt,  and  others,  pure  cul- 
tures of  the  tubercle  bacilli  were  employed.  Many  negative  results  were 
obtained  by  other  experimenters,  such  as  de  Thoma,  Celli  and  Guarnieri, 
Cadeac  and  Malet.  Cornet  believed  these  failures  due  to  the  fact  that 
conditions  similar  to  those  of  natural  infection  were  not  obtained.  In 
1898  he  placed  48  guinea  pigs  in  a  large  room,  at  different  heights 
above  the  floor  and  in  different  parts  of  the  room.  Dried  s])utuni  was 
])laced  on  tlie  carpet  and  broken  up  and  distributed  by  sweeping.  Of 
the  48  guinea  pigs,  47  contracted  tuberculosis  of  the  bronchial  glands 
and  lungs,  with  partial  cavity  formation.  This  work,  in  common  with 
most  inhalation  experiments,  is  o])en  to  the  very  grave  objection  that 
no  attempt  was  made  to  close  the  esophagus,  and  it  is  certain  that  some 
of  the  bacillus-laden  dust  was  swallowed. 

Xenninger  has,  however,  shown  that  when  rabbits  are  forced  to 
breathe  air  laden  with  the  Bacillus  prodigiosus,  cultures  can  be  recov- 
ered from  the  finest  bronchi.  Similar  observations  have  been  made  by 
Paul,  Fischer,  Beitzke,  etc.  Findel,  working  with  Fliigge,  has  infected 
dogs  and  a  calf  by  blowing  a  spray  of  bovine  tubercle  bacilli  into  the 
trachea,  which  had  been  previously  opened.  At  autopsy,  tuberculosis  of 
the  lungs  was  found,  while  the  tonsils,  cervical,  retropharyngeal,  and 
mesenteric  glands  were  free  from  disease,  both  macroscopic  and  micro- 
scopic. Schultze  has  repeated  some  of  Calmette's  experiments,  and 
though  after  feeding  pigment  it  w'as  found  only  in  the  lungs,  he  believes 
that  it  reached  them  through  aspiration.  He  does  not  consider  that  the 
use  of  a  stomach  tube  excludes  the  ])ossibility  of  inhalation.  In  a  rabbit 
he  introduced  pigment  into  th^  stomach  through  a  fistula  for  two 
months,  and  at  death  was  unal)le  to  find  any  deposit  in  the  lungs. 

Spronk  also  believes  that  the  aspiration  of  food  particles  frequently 
takes  place  even  when  a  stomach  tube  is  employed.  Under  his  direc- 
tion Nieuwenh-uyse  carried  out  feeding  experiments  similar  to  those  of 
Vansteenberghe  and  Grysez,  but  in  only  one  animal  was  the  pigment 
recovered  in  the  lung,  and  this  was  believed  to  be  due  to  aspiration. 

In  view  of  the  evidence  at  hand,  and  which  is  constantly  accumu- 
lating, it  may  be  said  that  infection  tlirough  the  alimentary  tract  is  not 
only  possible,  but  unquestionably  occurs  in  a  large  proportion  of  cases. 
In  children,  especially,  it  occupies  a  position  almost,  if  not  quite,  as 
important  as  respiratory  infection.  It  must  not  be  understood  that  the 
source  of  such  infection  is  always  food.  Dust  which  reaches  the  uj)per 
air  passages  and  mouth  is  constantly  swallowed  with  the  saliva  and 
nasal  secretion.  The  frequency  with  which  the  bovine  tubercle  bacillus 
has  ])ecn  found  in  children  slious,  howevei',  that  food  is  often  respon- 
sible foi'  the  infection. 


46  ETIOLOGY— THE  TUBERCLE   BACILLUS 


ADDENDA 

Sinnvtari)  of  Bacteriulogical  Work  Presented  at  the  International  Con- 
gress, Washington,  D.  C. 

Viability  of  the  Tubercle  Bacillus. — Dr.  M.  J.  Kosenaii  has 
carried  out  extensive  experiments  on  the  viability  of  the  tubercle  bacillus, 
lie  points  out  the  difficulty  of  telling  dead  from  living  tubercle  bacilli 
by  inoculation,  owing  to  the  production  of  tubercles  by  the  dead  germ, 
and  shows  the  necessity  of  making  secondary  inoculations  in  all  doubt- 
ful cases.  The  tubercle  bacillus  is  killed  surely  by  a  temperature  of 
60°  C.  continued  for  twenty  minutes. 

Types  of  the  Tubercle  Bacillus. — Professor  Arloing  is  a  stanch 
believer  in  the  unity  of  the  tubercle  bacillus.  All  the  variations  in 
virulence  and  morphology  are  simply  changes  brought  about  by  envi- 
ronment. The  human  bacilli,  as  obtained  from  different  types  of  the 
disease,  show  marked  variation  in  virulence.  This  variation  is  as 
marked  as  is  the  difference  usually  found  between  the  human  bacilli 
and  the  bovine  bacilli.  He  has  modified  both  bovine  and  human  bacilli 
by  special  methods  of  culture,  showing  that  it  is  possible  in  this  way 
to  lower  or  increase  the  virulence.  He  has  even  produced  types  closely 
allied  to  the  avian  bacillus.  From  the  standpoint  of  hygiene  his  studies 
emphasize  the  importance  of  guarding  against  all  types  of  the  tubercle 
virus,  whatever  may  be  the  origin. 

Investigations  into  the  Eelations  between  Human  and  Bovine 
Tuberculosis. — Profs.  J.  Fibiger  and  C.  0.  Jensen  have  made  an  elabo- 
rate investigation  on  tliis  point.  The  authors  hold  strongly  to  the  unity 
of  the  tubercle  bacillus,  and  do  not  admit  a  sharp  distinction  between 
the  bacilli  usually  spoken  of  as  hunum  and  bovine.  A  number  of  cul- 
tures show  transitional  forms  having  some  of  the  characteristics  of  the 
bovine  and  others  of  the  human  type.  They  believe  strongly  in  the 
danger  to  mankind  from  bovine  infection.  Dr.  Nathan  Eaw  admits  of 
the  differentiation  of  the  tubercle  bacillus  into  two  types,  the  human  and 
the  bovine.  He  holds  strongly  to  the  belief  that  the  bovine  bacillus  is 
highly  virulent  for  mankind,  and  produces  certain  types  of  tuberculosis 
as  a  rule.  These  are  peritonitis,  lymphadenitis,  acute  miliary  tubercu- 
losis, meningitis,  arthritis,  and  lupus.  The  human  type  of  the  tubercle 
bacillus  produces  usually  pulmonary  tuberculosis,  ulceration  of  the  in- 
testines, and  laryngitis.  He  believes  that  an  infection  by  the  human 
type  protects  against  bovine  infection,  and  vice  versa.  In  his  practice 
he  uses  the  tuberculins  in  accordance  with  this  view.  He  has  treated 
about  two  hundred  eases  of  tuberculosis  with  the  various  tuberculins, 
and  is  greatly  encouraged. 


ADDENDA  47 

Intertransmissibility  of  Tuberculosis. — Dr.  Charles  F.  Dawson 
liokls  strongly  to  the  danger  to  mankind  of  hovine  infection.  The  wide 
range  of  pathogenic  power  of  the  bovine  tubercle  bacillus  makes  it 
practically  certain  that  it  is  pathogenic  for  man  also.  The  infection 
comes  usually  from  ingesting  the  products  of  tuberculous  cattle,  infec- 
tion taking  place  through  the  alimentary  canal. 

Susceptibility  of  Cattle  to  the  Surgical  Forms  of  Tubercu- 
losis.— Susceptibility  of  cattle  to  the  surgical  forms  of  tuberculosis  has 
been  studied  by  Dr.  R.  R.  Dinwiddie.  Intraperitoneal  inoculations  of 
material  obtained  from  two  cases  of  glandular  tuberculosis,  one  of  arth- 
ritis, and  one  of  genito-urinary  tuberculosis,  were  made  in  yearlings 
without  effect.  The  writer  has  believed,  with  Dr.  Raw,  that  certain 
forms  of  tuberculosis  are  of  bovine  origin,  which  has  not  been  confirmed 
by  his  experiments. 

Dr.  Charles  W.  Duval  has  studied  the  tubercle  bacilli  isolated  directly 
from  the  tissues  of  four  human  bodies,  the  disease  in  each  case  begin- 
ning with  cervical  adenitis,  and  death  occurring  in  from  six  to  eight 
weeks  after  the  first  symptoms.  All  cases  showed  primary  lesions  in  the 
cervical  region  and  acute  general  miliary  tuljerculosis.  Of  the  four 
cultures  one  was  human  in  character  and  one  bovine,  the  two  others 
representing  intermediate  forms,  one  approaching  bovine  and  the  other 
the  avian  type.  Inoculations  of  animals  with  these  led  him  to  suspect 
the  possible  relation  between  Hodgkin's  disease  and  such  bacilli. 

Drs.  J.  X.  Davalos  and  J.  Cartaya  have  examined  a  series  of  cases 
in  human  beings  and  failed  to  isolate  the  bovine  bacillus  from  any  of 
them.     Xumber  of  cases  not  given. 

Dr.  Hidego  Xoguchi  has  shown  that  oleate  soaps  have  the  power  of 
modifying  the  virulence  of  tubercle  bacilli.  According  to  the  concen- 
tration used  the  virulence  of  the  tubercle  bacilli  is  so  modified  as  to 
infect  guinea  pigs  slightly  or  not  at  all.  The  guinea  pigs  which  failed 
to  develop  tuberculous  lesions  following  the  inoculation  acquired  a 
definite  degree  of  immunity  to  virulent  bacilli.  The  oleate  soaps  showed 
the  same  effect  on  tubercle  bacilli  cultures,  very  small  amounts  inhibit- 
ing the  growth  or  preventing  it  completely.  The  bactericidal  effect  of 
these  soaps  is  much  greater  than  that  of  the  component  parts  used 
separately.  He  believes  that  those  substances  derived  by  autolysis  from 
organs  which  are  actively  bactericidal  contain  lipoids,  and  that  soaps 
formed  during  autolysis  are  important,  if  not  the  chief,  factors  in  this 
bactericidal  action. 

Drs.  N.  Jancso  and  A.  Elfcr,  from  an  extensive  series  of  studies 
made  on  !)3  tuberculous  persons,  11  bovines,  1  pig.  and  18  chickens,  lind 
thai  all  types  of  bacillus  isolated  nmy  !)('  divided  rather  sharply  inl<» 
three  groups — human,  bovine,  and  avian.     Among  the  cultures  derived 


48  ETIOLOGY— THE  TUBERCLE   BACILLUS 

from  Imnian  beings,  one  showed  all  the  characteristics  of  the  avian  type, 
the  others  all  belonging  to  the  human  type.  The  bacillus  obtained  from 
the  pig  belonged  to  the  bovine  type.  They  find,  however,  that  among 
cultures  which  can  be  placed  in  one  category  or  the  other,  there  are 
marked  differences  in  many  of  tlieir  characteristics  and  in  virulence. 
They  obtained  a  number  of  cultures  from  human  beings  which  produced 
death  in  rabbits,  though,  as  a  rule,  their  human  cultures  showed  ver}' 
slight  virulence  for  rabbits.  Cultures  obtained  from  the  different  organs 
of  one  and  the  same  individual  also  showed  marked  variation  in  impor- 
tant characteristics.  They  find  that  it  is  relatively  easy  to  modify  the 
characteristics  of  the  various  acid-fast  organisms  isolated,  especially 
their  pathogenicity.  They  have  not,  however,  succeeded  in  giving  them 
any  specific  properties,  and  believe  that  in  nature  the  more  important 
groups  tend  to  l)ecome  more  and  more  clearly  differentiated,  one  from 
the  other. 

Courmont  (J.)  and  Lesieur  show  tliat  infection  may  be  produced  in 
calves,  rabbits,  and  guinea  pigs  through  the  uninjured  skin  if  the  culture 
used  is  sufficiently  virulent.  Inoculations  with  p])utum  are  not  as  effec- 
tive as  those  made  witli  jmre  cultures.  In  one  third  of  tlie  infections  the 
skin  shows  no  trace  of  the  passage  of  bacilli,  in  one  third  we  find  sliglit 
indurations  or  small  scabs,  and  in  one  third  warty  tulx'rcles  are  found. 
The  skin,  therefore,  does  not  form  an  impossible  barrier  to  the  tul>ercle 
bacillus,  even  when  apparently  intact.  Abrasions  and  minor  injuries 
may  form  portals  of  entry  for  distant  lesions.  The  absence  of  a  local 
lesion  does  not  disprove  this  mode  of  infection.  In  rabbits  we  may 
have  a  pulmonary  lesion  resulting  from  percutaneous  infection,  a 
marked  example  of  a  lesion  originating  at  a  point  far  removed  from 
the  point  of  entry  of  the  bacillus. 

Carl  Frankel  also  produced  infection  in  guinea  pigs  through  the 
apparently  intact  skin.  Dr.  Isador  Spitzstein  has  performed  similar 
experiments  with  entirely  negative  results,  and  concludes  that  if  per- 
cutaneous infection  is  possible  at  all  it  is  the  most  unfavorable  route 
for  the  tubercle  bacillus  to  enter  the  body. 

Cultural  Characteristics  of  Tubercle  Bacilli. — Dr.  Johann 
von  Szaboky  finds  that  agar  made  from  lung  tissue  forms  the  best 
medium  for  growth  of  the  tubercle  l)acillus.  The  next  best  media  are 
sputum-agar,  sjnitum-lung-agar,  and  tuberculous  lung-agar.  The  best 
reaction  of  media  varies  with  the  media.  In  general  feebly  acid  media 
seem  best.  Very  moist  media,  like  lung-agar,  gave  best  results,  and  dry 
media  least  good.  The  tubercle  bacillus  changes  the  reaction  of  the 
medium  during  growth.  Most  media  showed  first  an  alkaline  reaction, 
which  changed  to  acid,  and  again  to  alkaline.  Agar  made  with  soinatose 
showed  changes  the  exact  reverse  of  this. 


ADDENDA  49 

Ctie:mistry  of  Tubercle  Bacilli. — Dr.  X.  C.  Vaughaii  finds  that 
the  tubercle  bacillus  after  being  freed  from  substances  soluble  in  ether 
and  alcohol,  may  be  split  into  two  portions  by  an  alcoholic  solution  of 
alkali — a  poisonous  and  nonpoisonous.  The  poisonous  portion  kills  ani- 
mals after  a  few  months  in  doses  of  75  to  100  mgm.  The  nonpoisonous 
portion  sensitizes  animals  to  the  whole  bacillus.  It  is  used  in  the  treat- 
ment of  human  tuberculosis,  but  it  is  too  early  to  say  whether  or  not 
it  is  better  for  this  purpose  than  old  tuberculin. 

Chamber  for  Handling  Dried  Tubercle  Bacilli. — Dr.  A.  P. 
Kitchens  has  devised  a  chamber  for  handling  dried  tubercle  bacilli  with 
perfect  safet}'.  It  consists  essentially  of  a  tight  chamber,  provided  wath  a 
suction  pump  and  a  cotton  filter  for  the  admission  of  air.  Manijnilation 
is  carried  out  by  means  of  rubber  gauntlets  sealed  into  the  wall  of  the 
chamber,  and  the  pump  is  operated  during  use.  After  use  the  pump 
is  cut  off  and  the  filter  box  closed,  formalin  and  lime  or  permanganate 
of  potash,  which  were  placed  in  the  chamber  before  use,  are  mixed, 
and  complete  disinfection  takes  place.  It  may  be  used  for  handling 
other  dry  biological  products. 

Action  of  Diffused  Light  on  Tubercle  Bacilli. — John  Wein- 
zirl,  Ph.D.,  finds  that  direct  sunlight  kills  the  tubercle  bacillus  in  from 
two  to  ten  minutes.  Diffused  light  always  killed  tubercle  bacilli  within 
one  Aveek,  sometimes  in  twenty-four  hours.  He  lays  stress  on  the  point 
that  no  medium  which  absorbs  light  shall  be  placed  between  the  bacilli 
and  the  light.  Moist  cultures  were  killed  sooner  than  dry  ones.  It 
seems  certain  that  light  in  dwellings,  etc.,  is  a  valuable  germicide. 

Flies  as  Agents  in  Dissemination  of  Tubercle  Bacilli. — Dr. 
Ch.  Andre  finds  that  flies  are  acfive  agents  in  the  spread  of  tubercle  ba- 
cilli, polluting  foodstufi^s  with  bacilli  adhering  to  feet  after  contact  with 
sputum.  After  feeding  on  tuberculous  sputum  they  evacuate  bacilli 
within  six  hours,  and  some  may  be  found  in  feces  as  long  as  five  days 
after.  Food  thus  polluted  by  flies  will  infect  guinea  pigs.  Flies  caught 
in  hospital  wards  produce  tuberculosis  in  guinea  pigs.  It  is  therefore 
of  prime  importance  to  disinfect  sputum  and  feces  promptly  and  to 
protect  them  from  flies.  Foods  must  also  be  protected  and  flies  de- 
stroyed as  far  as  possible. 

The  transmissibility  of  bovine  tuberculosis  to  human  beings 
was  discussed  at  a  conftn-ence  in  rainera.  The  trend  of  the  discussion 
was  put  into  the  hands  of  Koch,  who  limited  it  to  two  (piestions — first, 
tlu!  frequency  of  intestinal  tuberculosis,  and  second,  the  occiirrciicc  of  I  Ik; 
bovine  bacillus  in  pulmonary  consumption. 

Tn  lf)01  Koch  said  "human  tuberculosis  differs  from  bovine  and 
cannot  be  transmiltcd  to  cattle,"  and  further  tliat  "  if  transmission  from 
cattle  to  man  ever  took  ]»lare.  it  was  so  rare  that  he  did  not  deem  it 


50  ETIOLOGY— THE  TUBERCLE   BACILLUS 

advisable  to  take  any  measures  against  it."  The  disproof  of  the  first 
statement  was  so  easy  tliat  observers  all  over  the  world  soon  gave  numer- 
ous cases  showing  its  error.  Many  private  workers,  as  well  as  a  British 
Eoyal  Commission  and  a  German  Imperial  Commission,  soon  showed 
the  fallacy  of  these  two  statements,  as  has  been  pointed  out  in  the  body 
of  this  book. 

Koch's  ground  having  been  sliown  to  be  untenable,  even  l)y  a  com- 
mission of  which  lie  was  a  member,  he  has  now  shifted,  and  makes  the 
claim  that  pulmonary  consumption  is  not  caused  by  the  bovine  germ. 
At  the  conference  in  question  he  made  the  following  statement,  "  I 
desire  to  put  myself  again  on  record  by  saying  that  I  have  never  denied 
that  bovine  tuberculosis  may  occur  in  human  beings,"  a  statement  which 
was  repeated  more  than  once.  His  general  conclusion,  as  given  in  his 
paper  before  the  Congress,  was  that  our  preventive  measures  must, 
therefore,  "  be  directed  jjrimarily  against  the  human  disease,"  an  opinion 
which  is  not  by  any  means  original  with  Koch,  but  is  held  all  over  the 
world,  even  l)y  those  men  who  believe  most  firmly  in  the  danger  to 
mankind  from  cattle  tuberculosis. 

In  reply  to  Koch's  demand  that  cases  of  pulmonary  tuberculosis 
due  to  the  bovine  tuberculosis  be  brought  forward,  Professor  Arloing  at 
once  gave  the  history  of  a  most  typical  case.  The  British  Eoyal  Com- 
mission also  reported  the  finding  of  bovine  bacilli  in  the  sputum  of 
a  consumptive.  It  will  be  remembered  also  that  the  German  Com- 
mission found  the  bovine  bacillus  in  a  case  of  miliary  tuberculosis  of 
the  lung,  though  Professor  Koch  now  denies  that  this  case  bears  on 
the  subject  at  all — a  method  of  reasoning  which  cannot  be  understood 
by  the  ordinary  mind.  In  miliary  tuberculosis  a  person  usually  dies 
before  the  tubercles  soften  and  the  case  becomes  an  open  one,  as  is  well 
known,  but  infection  of  the  lung  from  the  intestinal  tract  is  proven 
by  a  case  of  miliary  tuberculosis  just  as  much  as  though  the  case  were 
one  of  ordinary  consumption.  In  fact,  miliary  tuberculosis  is  believed 
to  be  the  result  of  a  large  number  of  bacilli  entering  the  blood  stream 
at  one  time.  The  evidence  then  is  strong  that  in  such  a  case  the  num- 
ber of  bacilli  gaining  entrance  to  the  system  from  the  intestinal  tract  is 
very  large. 

Taking  up  the  second  point,  in  regard  to  the  rare  occurrence  of  pri- 
mary intestinal  tuberculosis,  Koch  quoted  at  length  from  Flligge.  He 
was  well  answered  by  Professor  Fibiger,  of  Copenhagen,  who,  while 
acknowledging  the  figures  quoted  from  Orth,  Baginsky,  and  others  as 
having  been  correct  for  the  year  1901,  called  attention  to  the  fact  that, 
without  exception,  these  same  men  had  in  more  recent  work  found  a 
greatly  increased  number  of  such  cases.  For  example,  Benda,  who  in 
1903  stated  that  he  had  found  only  2  or  3  cases  during  some  eighteen 


ADDENDA  51 

iiiontlis,  ill  liXto  said  tliat  the  frequency  ol'  this  form  oL"  tuljerciilosis  was 
greater  tlian  he  originally  thought.  Orth,  wlio  in  1904,  during  a  period 
of  fifteen  months,  reported  2  eases  among  33  children,  in  1905  during 
twenty-two  months  reported  6  cases  among  77  children.  Baginsky,  who 
in  1901  had  not  ohserved  a  single  case  of  primary  intestinal  tuberculosis, 
found  6  cases  among  144  children  in  1903,  and  30  cases  among  389 
children  in  1905.  Even  these  figures  do  not  reach  those  given  by 
Heller,  Hof,  von  AVagener,  Edens,  and  others. 

One  of  two  conclusions  is  obvious,  either  that  these  pathologists  are 
finding  more  intestinal  tuberculosis  since  their  attention  has  been  di- 
rected to  it,  or  else  there  has  been  a  great  increase  in  this  form  of  disease. 
Has  this  been  brought  about  through  carelessness  in  the  use  of  milk 
from  tuberculous  cattle,  since  Koch  has  publicly  announced  that  there 
was  little  or  no  danger  from  such  use? 


CHAPTER   II 

TUBERCLE    AXD    MORBID    ANATOMY 

(General  and  Pulmonary  Tuhercniosis) 

By   LUDVIG  HEKTOEN 

HISTOGENESIS    AND    FATE 

Tuberculosis  is  the  result  of  the  activities  of  the  tubercle  bacillus, 
which  arouses  in  the  body  various  reactive  changes.  Anatomically, 
tuberculosis  manifests  itself  most  characteristically  and  most  commonly 
by  the  development  of  avascular  cellular  masses  or  tubercles  (Baillie, 
1794;  Bayle,  1810),  but  it  also  may  appear  in  other  forms,  more  par- 
ticularly as  diffuse  granulation  tissue  and  as  exudative  inflammations. 
The  designation  "  tuberculous "  is  applicable  to  all  the  changes  caused 
by  the  tubercle  Itacillus,  no  matter  whether  tubercles  are  present  or  not. 

Origin  of  Tubercle. — The  tubercle  is  produced  primarily  by  multi- 
plication of  the  fixed  cells,  especially  of  connective  tissue  and  of  capil- 
lary endothelium  at  the  site  of  the  localization  of  the  microbes. 

The  exact  mode  of  action  whereby  this  cellular  proliferation  is 
started  has  not  yet  been  explained  with  convincing  clearness,  but  vari- 
ous interpretations  have  been  offered.  Perhaps  the  most  widely  accepted 
explanation  is  that  l)y  Weigert,  Avho  regarded  the  cellular  processes  as 
essentially  secondary  to  "  injury  "  to  cells  and  to  intercellular  substance 
by  an  immediate  action  of  the  bacillus.  In  most  tissues  the  obtainable 
morphologic  indications  of  such  direct  injury  are  not  very  striking; 
in  tuberculosis  of  the  placenta,  however,  Warthin  ('07)  finds  unmis- 
takable evidence  of  primary  chemico-toxic  action  by  the  tubercle  bacil- 
lus in  the  form  of  minute  areas  of  necrosis,  about  which  typical  tuber- 
cles subsequently  develop. 

As  a  rule  the  first  definite  result  of  the  invasion  of  many  tissues 
by  tubercle  bacilli  has  been  found  to  be  (Baumgarten.  '8.5)  swelling 
and  mitotic  division  of  the  fixed  cells,  which  usually  arrange  themselves 
in  a  somewhat  radiating  manner  about  the  bacilli,  some  of  which  soon 
appear  within  the  cells.  Because  the  cells  may  present  rounded  and 
I)olygonal  bodies  with  vesicular  nuclei,  and  appear  to  be  connected  with 
one  another,  Virchow  designated  them  as  ""  epithelial ''  cells,  and  they 
52 


HISTOGENESIS  AND   FATE  53 

are  now  commonly  ilocribed  as  rpitheUoid.  As  tlie  epithelioid  cells  of 
tubercles  in  most  cases  represent  proliferative  connective-tissue  cells  and 
endothelial  cells,  they  correspond  in  every  way  to  thp  fibroblasts  in  non- 
tuberculous  inflammatory  processes. 

In  parenchymatous  organs  tuhercle  formation  is  commonly  asso- 
ciated with  evidences,  in  the  form  of  mitotic  figures,  of  active  multipli- 
cation of  the  specific  cells  of  the  parenchyma.  This  is  .seen  both  in  the 
hepatic  cells  and  in  the  epithelium  of  the  l)ile  ducts,  in  the  neighbor- 
hood of  developing  tul)ercles  in  the  liver,  and  in  the  epithelium  of  the 
uriniferous  tnl)ules  about  renal  tubercles.  It  cannot  l)e  said,  however, 
that  it  has  been  satisfactorily  estal)lished  that  the  derivatives  of  such 
cells  regularly  become  constituent  elements  of  tubercles.  When  tuber- 
cles develop  in  the  neighborhood  of  epithelial  cells — i.  e.,  in  the  skin 
or  mucous  membranes — these  may  also  increase  in  number  and  volume 
and  undergo  other  changes,  but  without  entering  into  the  real  structure 
of  the  tubercle. 

The  occurrence  of  typical  tubercles  in  the  midst  of  fibrinous  exu- 
dates, without  any  direct  connection  with  tissues,  is  urged  as  proof  of 
the  correctness  of  the  view  that  tubercles  develop  wholly  from  emigrated 
leucocytes  which  may  form  both  the  epithelioid  and  other  cells.  It 
must  be  acknowledged  that  many  tubercles  in  exudates  can  be  formed 
only  from  cells  with  spontaneous  motion.  Young  connective-tissue  cells 
possess  this  faculty,  however,  and  there  is  no  good  reason  known  why 
they  mav  not  wander  out  into  fibrinous  exudate  in  response  to  positive 
chemotaxis,  and  aggregate  about  tubercle  bacilli  at  the  same  time  as 
lymphocytes  and  leucocytes  gather  about  and  perhaps  invade  the  growth. 

Frequently,  but  not  always,  niultinuclear  giant  cells  form  a  con- 
spicuous element  in  tubercles,  even  at  an  early  stage.  Much  thought 
has  been  given  to  the  explanation  of  giant  cells,  and  at  present  two 
modes  of  formation  are  generally  accepted.  Probably  rapid,  commonly 
amitotic  nuclear  division  or  fragmentation,  unaccompanied  with  corre- 
sponding division  of  the  cells,  is  regarded  as  the  more  important.  The 
failure  of  the  cell  to  divide  is  ascribed  by  Baumgarten  and  Weigert  to 
local  necrotic  or  retrogressive  changes  in  the  cell  body.  It  is  also  be- 
lieved that  giant  cells  form  by  the  fusion  of  several  adjacent  cells ;  on 
account  of  the  large  number  of  nuclei  often  present,  it  has  been  sug- 
gested that  in  this  case  also  there  may  be  rapid  nuclear  division. 

The  typical  tuberculous  giant  cell  (Langhans,  '68)  sends  out  many 
branching  processes  and  contains  numerous  oval,  vesicular  nuclei  which 
are  arranged  more  or  less  regularly  or  semicircularly  at  the  periphery 
or  massed  together  in  one  or  two  places.  The  anuclear  part  of  the  cell 
commonly  shows  evidences  of  necrobiosis,  which  is  ascribed  to  the  action 
of  bacilli  taken  up  by  the  cell. 


54  TUBERCLE  AND  MORBID  ANATOMY 

A  large  amount  of  discussion  lias  been  given  to  tlie  nature  and 
significance  of  the  giant  cells  of  tuberculosis.  Baumgarten,  Weigert, 
and  others  have  held  that  the  giant  cell  is  an  element  that  is  on  its 
way  to  destruction  from  the  very  first  and  that  it  fails  to  divide  because 
of  the  necrol)iotic  action  of  the  bacilli  it  usually  harbors.  Metchnikoff, 
on  the  contrary,  has  championed  the  view,  which  now  is  more  generally 
accepted,  namely,  that  the  giant  cells  of  tuberculosis,  like  multinuclear 
])lasmodial  masses  in  general,  begin  their  existence  as  active  pliagocytes. 
The  fact  that  they  are  often  destroyed  has  not  changed  this  conception 
because  this  fate  they  suffer  in  common  with  all  the  colls  in  active 
and  progressive  tuberculosis.  Among  the  indications  that  the  giant 
cells  are  active  phagocytes,  at  least  at  first,  may  be  mentioned  the  occur- 
rence within  them  of  disintegrating  and  disintegrated  bacilli.  Koch 
was  the  first  to  point  this  out.  In  certain  animals  (SpermopJiilus  gut- 
talus,  Algerian  rat)  Metchnikoff,  and  also  Welcker,  note  calcareous  and 
also  ferruginous  incrustation  of  what  they  regard  as  bacilli  within 
giant  cells  in  experimental  tubercles,  and  Metchnikoff  thinks  that  cal- 
cium salts  and  other  substances  are  laid  down  by  the  giant  cell  itself 
in  the  reaction  against  the  bacillus.  Calcareous  concretions,  the  exact 
nature  of  which  is  not  clear  (bacilli,  elastic  fibers?),  also  occur  in  giant 
cells  in  human  tuberculous  lesions.  That  the  giant  cells  are  not  merely 
retrogressive  structures  is  shown  by  their  power  under  certain  condi- 
tions to  subdivide  into  cells  that  develop  further. 

True  giant  cells  may  be  simulated  by  cross  sections  of  hyaline  thrombi 
in  capillaries  or  minute  vessels,  with  confluence  of  the  endothelial  cells. 
This  is  not  a  real  giant  cell;  as  a  rule  it  is  a  circular  body  with  smooth, 
definite  outlines,  and  the  study  of  serial  sections  may  be  necessary  in 
order  to  determine  its  real  nature  and  origin. 

Sooner  or  later  leucocytes  in  variable  numbers  gather  at  the  periphery 
of  the  newly  formed  nodule  and  contribute  to  its  enlargement.  These 
cells  are  mostly  small,  mononuclear,  round  cells  (lymphocytes),  and 
correspond  to  the  small  round  cells  in  simple  inflammatory  infiltrations 
(Maximow's  "  polyblasts,"  Marehand's  "  leukocytoids  ").  In  many  cases 
they  may  crowd  into  the  tubercle  and  force  the  epithelioid  cells  apart 
(lymphoid  tubercle)  ;  in  other  cases  they  may  be  present  in  very  small 
numbers.  Later  still,  especially  when  degenerative  changes  occur, 
polymorphonuclear  cells  may  accumulate,  sometimes  in  such  numbers 
that  the  tubercles  appear  surrounded  and  invaded  by  purulent  infiltra- 
tion. It  seems  that  the  greater  the  number  of  bacilli,  the  more  marked 
the  inflammatory  changes;  whereas  the  slower  the  growth,  and  the 
fewer  the  bacilli  the  more  numerous  will  be  the  epithelioid  and  giant 
cells. 

At  the  same  time,  as  there  is  migration  of  leucocytes,  there  is  also 


HISTOGENESIS   AND   FATE  55 

more  or  less  serous  exudation  into  the  newly  formed  nodule.  The  amount 
of  fibrin  in  tubercles — coagulable  inflammatory  exudate — is  subject  to 
great  variation  even  in  the  same  organ,  and  is  dependent  on  the  degree 
of  injury  to  the  blood-vessels,  which  in  turn  may  be  determined  by 
the  number,  relative  virulence,  and  location  of  the  invading  bacilli. 
Tubercles  also  occur  without  any  demonstrable  fibrin.  The  slower 
the  development  of  the  changes,  because  of  relatively  low  virulence  on 
the  part  of  the  bacilli  or  because  of  relatively  greater  resistance  on  the 
part  of  the  tissue,  the  more  marked  the  proliferative  as  distinguished 
from  the  exudative  processes  in  the  tuberculous  lesion   (Orth). 

The  intercellular  fibrillar  framework,  which  is  demonstrable  in  all 
tubercles  but,  as  a  rule,  most  apparent  in  the  margins,  is  kno^vn  as  the 
reticulum.  It  is  an  essential,  preformed  constituent,  and  not,  as  some- 
times stated,  the  result  of  the  action  of  fixing  solutions.  This  reticu- 
lum  is  derived,  at  least  in  part,  from  fibrillation  and  rarefaction  of  the 
ground  substance  of  the  tissue  in  which  the  tubercle  forms,  the  pro- 
liferating cells  forcing  the  fibers  apart  until  they  become  drawn  out  and 
thin  in  places,  perhaps  destroyed.  (The  elastic  fibers  in  the  old  tissue 
disappear.)  Then,  too,  the  new  cells  composing  the  tubercle  often  send 
out  long  interlacing  processes  which  surround  the  cells ;  this  is  especially 
true  of  the  giant  cells,  the  processes  of  which  have  been  likened  to 
spider's  feet. 

It  is  worthy  of  special  emphasis  that  not  only  are  new  vessels  not 
formed  in  tubercles,  but  also  that  the  preexisting  vessels  at  the  site  of 
developing  tubercles  commonly  undergo  obliteration. 

At  the  height  of  its  progressive  development,  when  the  purely  pro- 
liferative changes  predominate,  the  tubercle  forms  a  small,  grayish, 
translucent  nodule,  the  granulation  tuherculeuse  of  Bayle  and  Laen- 
nec,  the  simple  tubercle  of  Virchow  and  others,  and  the  "  granulation- 
tuberculosis  "  of  von  Behring.  Commonly  likened  in  size  to  that  of  a 
millet  seed,  it  is  in  reality  smaller  (submiliary),  as  emphasized  long 
ago  by  Virchow  and  more  recently  by  von  Behring.  Sooner  or  later  cer- 
tain retrogressive  changes  may  occur  in  conse(|uence  of  which  the 
tubercle  becomes  somewhat  larger,  opaque,  whitish,  yellowish- white  or 
grayish-wliite  (Laennec's  miliary  tubercle).     This  is  caseation. 

Tuberculous  Granulation  Tissue. — In  addition  to  the  formation  of 
tubercles,  the  invasion  of  tissues  by  tubercle  bacilli  may  result  in  the  de- 
velopment of  a  diffuse,  vascular  granulation  tissue  which  is  distinguished 
by  the  presence  within  it  of  the  specific  bacillus,  by  occasional  giant  cells 
and  tubercles,  and  by  a  tendency  to  retrogressive  changes  or  caseation. 
This  form  of  reaction  on  the  part  of  the  tissues  occurs  mostly  when  large 
numbers  of  bacilli  and  their  products  are  brought  into  contact  with 
extensive  surfaces,  as  occurs  when  numerous  bacilli  are  excreted  by  the 


56  TUBERCLE  AND  MORBID  ANATOMY 

kidneys  or  when  serous  membranes  are  hatlie^l  by  exudate  ricli  in 
bacilli. 

Tuberculous  Exudative  Inflammation. — The  tubercle  bacillus  is 
capable  also,  as  are  its  products,  of  causing  diffuse  typical  inflammation 
with  serous,  fibrinous,  or  purulent  exudation.  Thus  there  are  certain 
forms  of  tuberculous  leptomeningitis  in  which  there  is  a  copious  sero- 
purulent  or  purulofibrinous  exudate,  without  much,  if  any.  tubercle 
formation.  And  in  the  lungs  especially  pure  exudative  tuberculous 
inflammations  may  occur  without  the  characteristic  tuberculous  prolif- 
erations. Laennec  was  the  first  to  include  this  form  of  pneumonia 
with  tuberculosis.     (See  Pulmonary  Tuberculosis.) 

Tuberculous  peritonitis,  pleuritis,  pericarditis,  and  synovitis  are 
often  marked  by  the  predominance  of  the  exudative  processes.  In  such 
exudates  the  predominating  cells  are  mononuclear  cells.  In  many  cases 
there  may  be  a  mixed  infection.  In  the  so-called  tuberculous  cold 
abscess  the  material  in  reality  is  not  pus,  as  ordinarily  understood,  but 
rather  a  debris  of  necrotic  cells  and  softened  caseous  material.  Un- 
doubtedly the  products  of  tubercle  bacilli  can  induce  true  suppuration, 
because  tuberculin,  according  to  Koch,  is  an  excellent  agent  for  the 
production  of  suppuration  experimentally. 

The  tuberculous  process  begins  with  the  formation  of  minute  foci 
which  arise  either  singly  or,  in  case  of  several  foci  of  infection,  in 
simultaneous  crops.  As  the  bacilli  multiply  new  foci  may  arise.  Com- 
monly the  tissue  about,  even  in  the  case  of  the  typical  tubercle,  pre- 
sents more  or  less  inflammatory  reaction  in  the  form  of  congestion, 
exudation,  cellular  immigration,  and  proliferation.  In  this  way  de- 
velop foci,  often  nodular,  especially  on  flat  surfaces,  and  of  varying 
extent  in  the  congested  grayish-red  tissue  of  which  the  character- 
istic tubercles  are  detected  more  or  less  readily  with  the  naked  eye 
as  minute  grayi.sh  or  grayish-yellow  nodules.  Now  if  the  infection 
is  arrested  promptly  almost  ideal  healing  may  be  accomplished.  But 
if  the  infection  spreads  into  the  adjacent  tissue,  and  this  is  the  more 
common  occurrence,  then  the  original  focus  enlarges  and  extends  as 
the  reactive  phenomena  continue;  sooner  or  later  caseation  takes  place, 
perhaps  with  softening  and  the  growth  of  fibrous  tissue,  and  in  this 
way  arise  chronic  tuberculous  foci  and  caseous  masses,  the  morbid 
anatomy  of  which  is  best  described  in  connection  with  tuberculosis  of 
the  different  organs. 

Caseation. — All  tuberculous  formations — tubercles,  diffuse  granula- 
tion tissue,  and  exudates — sooner  or  later  undergo  the  peculiar  form  of 
necrosis  termed  caseation.  Dead  caseous  tissue  has  an  appearance  quite 
similar  to  that  of  cheese.  In  caseation  the  cells  lose  their  outlines, 
become  irregular,  refuse  to  stain,  and  are  finally  converted  into  struc- 


HISTOGENESIS  AND   FATE 


di 


tureless  masses  and  detritus  (Fig.  5).  Wells  ("07)  points  out  that  case- 
ous matter,  like  cheese,  is  a  mixture  of  coagulated  proteid  and  finely 
divided  fat,  so  that  the  reasons  for  the  gross  resemblance  of  caseous  ma- 


■■^::-T<t-: 


':^r 


V.:,.i" '■■■.' 


:i.^ 


Fig.  5. — Tubercle  in  Lung  Tissue.  Surrounding  tissue  showing  only  slight  in- 
flammatory changes;  caseous  center  of  tubercle;  in  periphery  infiltration  with 
round  cells  and  several  giant  cells.     (From  Karg  and  Schmorl.) 

terial  to  cheese  is  quite  apparent.  The  proteid  caseous  material  is  almost 
wholly  coagulated  proteid,  from  which  the  products  of  nuclear  disin- 
tegration have  disappeared.  Caseation  differs  from  simple  coagulation 
necrosis  by  the  presence  of  a  large  amount  of  fat. 

The  cause  of  the  coagulation  in  caseous  necrosis  is  not  clear.  Wells 
suggests  that  it  may  be  the  same  as  in  anemic  infarcts,  inasmuch  as 
tuberculous  tissues,  as  a  rule,  are  decidedly  anemic.  It  is  possible  that 
the  tul)ercle  bacillus  produces  substances  which  coagulate  proteids,  and 
Auclair  claims  that  the  fatty  si;bstance  that  can  be  extracted  from 
tubercle  bacilli  by  chloroform  is  the  cause  of  caseation. 

The  amount  of  fat  in  caseous  material  is  large.      In  material   from 


58  TUBERCLE  AND  MORBID  ANATOMY 

tuberculous  bovine  lymph  nodes,  Wells  found  22.7  to  23.1)  per  cent  of 
the  organic  material  soluble  in  alcohol  and  ether.  The  fatty  substances 
may  be  derived  from  disintegrated  cells,  and  the  fact  that  in  microscopic 
sections  most  of  the  fat  is  found  in  the  periphery  of  caseous  areas 
suggests  that  fat  passes  in  from  outside.  A  certain  though  small  amount 
of  fat  is  probably  derived  from  the  bodies  of  the  tubercle  bacilli. 

The  persistence  of  caseous  areas  for  a  long  time  indicates  that  the 
autolytic  enzymes  are  destroyed  early.  Leucocytes  are  not  attracted 
by  ordinary  caseous  material,  but  when  softening  occurs  from  mixed 
infection,  chemotactic  substances  develop  and  leucocytes  enter  freely. 

In  the  earlier  stages  caseation  is  associated  with  the  appearance  of 
firmly  coagulated  substances  between  the  cells,  evidently  derived  from 
the  l)lood  and  called  "  fibrinoid  "  by  Schmaus  and  Albrecht  because  it 
bears  resemblance  to  fibrin.  This  substance  does  not  react  with  the 
Weigert  stain  for  fibrin,  but  stains  yellow  with  Van  Gieson's  stain. 
The  presence  of  this  fibrinoid  substance  is  probably  one  reason  for  the 
firmness  and  dryness  of  caseous  material. 

In  tuberculosis  caseation  begins  centrally  and  progresses  peripherally. 
In  stained  preparations  the  caseous  parts  are  characterized  by  the  absence 
of  staining.  At  the  border  of  advancing  caseation  the  nuclei  present 
the  appearances  characteristic  of  karyorrhexis,  and  numerous  chromatin 
splinters  occur.  In  tuberculous  granulation  tissue  caseation  often 
spreads  uniformly,  so  that  large  superficial  patches  are  found  as  seen 
often  in  tuberculosis  of  the  genito-urinary  tract. 

Tuberculous  exudates  also  undergo  caseation.  When  the  exudate 
contains  cells  these  are  first  converted  into  caseous  detritus,  whereas 
the  fibrin  persists  for  some  time.  In  this  way  caseous  hepatization  in  the 
lungs  may  show  complete  caseation  of  the  central  part  of  the  contents  of 
the  alveoli,  while  the  peripheral  fibrinous  parts  of  the  exudate  remain 
intact.  Sooner  or  later  the  fibrin  also  loses  its  typical  staining  reac- 
tion and  becomes  transformed  into  caseous  material,  the  process  extend- 
ing even  to  the  alveolar  walls,  the  elastic  fibers  of  which,  however, 
resist  the  process  after  all  other  structures  have  succumbed,  so  that  it 
is  not  uncommon  to  find  well-preserved,  elastic  framework  in  parts 
of  the  lung  that  have  undergone  so  complete  caseation  that  not  a  single 
nucleus,  cell  body,  or  fibrin  thread  is  visible. 

Caseous  foci  may  become  calcified.  At  first  the  calcareous  matter, 
according  to  Wells  ('07),  appears  as  small  granules  which  later  may 
coalesce  into  larger  masses  and  concretions.  Old  caseous  and  calcified 
masses  are  generally  surrounded  by  more  or  less  sclerotic  connective- 
tissue  capsules,  which  develop  principally  from  the  cells  in  the  vicinity 
rather  than  from  the  tu1)orculous  cells  themselves,  which,  however,  may 
take  some  part  in  this  formation.     Caseous  matter,  even  when  definitely 


HISTOGENESIS   AND   FATE  59 

encapsulated,  often  contains  virulent  tubercle  l)acilli  in  lart^e  nuinhers. 
Sometimes  the  number  of  ])acilli  present  is  enormous.  Bacilli  capable 
of  causing  tul^erculosis  in  guinea  pigs  may  be  present  even  when  some 
degree  of  calcification  has  occurred,  but  when  calcareous  matter  forms 
the  principal  part  of  the  mass,  bacilli  are  rarely  demonstrable.  In  a 
given  case  it  is  quite  impossible  to  say  whether  bacilli  are  present  or 
not  in  caseous  or  calcareo-caseous  foci   (Bugge,  '96). 

Healing. — The  healing  of  tuberculous  processes  is  always  associated 
with  the  formation  of  connective  tissue,  which  may  be  derived  either 
from  the  cells  in  the  vicinity  of  the  tuberculous  area  or  from  the  tuber- 
culous cells  themselves,  more  commonly  by  far  the  former.  In  all  cases 
of  chronic  tuberculosis  there  is  formed  new  fibrous  tissue,  which  re- 
strains and  limits  the  spread  of  the  disease,  and  very  often  replaces  to 
a  greater  or  less  extent  the  tuberculous  formations.  Unfortunately  such 
replacement  is  only  too  often  incomplete,  the  disease  perhaps  spreading 
slowly  at  the  periphery,  at  the  same  time  as  healing  and  cicatrization 
take  place  at  the  center.  As  pointed  out,  caseous  material  is  not  at 
all  easily  absorbed,  and  inasmuch  as  it  may  contain  tubercle  bacilli, 
even  when  definitely  encapsulated  and  partly  calcified,  sclerotic  districts 
containing  caseous  or  calcareo-caseous  foci  can  not  be  regarded  as  com- 
pletely healed,  but  rather  as  having  passed  into  a  state  of  latency. 

Xaturally  the  fibrous  tissue  that  develops  in  connection  with  chronic 
tuberculous  processes  by  its  shrinking,  often  gives  rise  to  contracting 
scars,  deformations,  and  in  the  case  of  tubular  organs  to  strictures.  In 
the  lungs,  especially,  large  masses  of  dense  fibrous  tissue  may  develop  in 
the  course  of  healing,  and  here  the  coincident  occlusion  of  lymph  vessels 
leads  to  progressive  accumulation  *of  inhaled  coal  dust  within  fibrous 
areas  which  become  black  and  slaty — slaty  induration. 

In  addition  to  caseation  and  calcification,  tuberculous  tissue  may 
undergo  direct  transformation  into  fibrous  tissue.  Genetically  the  epi- 
thelioid cells  in  tubercles  are  fibroblasts  derived  from  connective  tissue 
and  endothelial  cells,  but  in  may  cases  these  cells  are  unable  to  produce 
mature  tissue  because  they  are  overtaken  by  caseation.  However,  under 
certain  conditions,  the  bacilli  being  promptly  destroyed  or  perhaps 
effectively  reduced  in  virulence,  the  epithelioid  cells  in  tubercles  may 
proceed  in  the  usual  way  to  form  mature  connective  tissue.  This  must 
be  regarded  as  the  most  ideal  mode  of  healing  of  tuberculosis.  The 
tubercle  now  becomes  transformed  into  connective  tissue  (fibroid  tuber- 
cle), Cruveilhier's  ('62)  fibroid  metamorphosis.  Giant  cells  may  per- 
sist in  the  interior  of  fibroid  tubercles.  According  to  v.  Rindtteisch, 
Klebs,  and  others  (Ilcktoen,  '98),  even  giant  cells  may  take  part  in 
Ihc  formation  of  connective  tissue  by  sul)(li\  idiiig  into  nuMicn»ns  indi- 
vidual, spindle-shaped  cells.     This  fact — namely,  thai   lubrriiilnu>  giant 


GO  TUBERCLE  AND  MORBID  ANATOMY 

cells  under  certain  conditions  undergo  progressive  changes — indicates 
that  they  are  not  merely  necrobiotic  elements  doomed  to  destruction 
from  their  inception,  as  claimed  by  Baumgarten  and  others.  On  the 
other  hand,  it  lends  support  to  the  view,  championed  by  Metclinikoff, 
that  they  are  active  phagocytes. 

POINTS  OF  ENTRANCE  AND  PRIMARY  LOCALIZATION  OF 
TUBERCLE  BACILLI 

The  determination  of  the  routes  of  entrance  of  tuberculosis  is  of 
great  importance,  because  of  the  light  thereby  thrown  on  the  source 
and  nature  of  the  infection,  and  the  indications  thus  obtainable  as  to 
the  best  means  of  prevention.  These  and  allied  questions  are  discussed 
elsewhere,  and  at  this  point  suffice  it  to  say  that  four  quite  distinct 
modes  of  entrance  must  be  recognized,  namely:  (1)  inhalation  of  bacilli 
present  in  dust  or  minute  droplets  of  sputum;  (2)  introduction  into 
the  digestive  tract  by  means  of  food  contaminated  with  bacilli  and  by 
other  means;  (3)  direct  implantation  on  the  skin  and  exposed  mucous 
surfaces  through  contact  with  infectious  material;  (4)  intra-uterine  in- 
fection through  the  placental  circulation. 

The  two  last  methods  of  infection  are  regarded  as  of  relatively  small 
importance,  and  there  now  exists  considerable  difference  of  opinion 
among  investigators  with  respect  to  the  comparative  significance  of  the 
first  two  modes,  but  the  evident  tendency  is  to  assign  far  greater  weight 
than  formerly  to  primary  infection  by  way  of  the  digestive  tract,  and 
more  especially  in  children  (Harbitz,  '05).^ 

The  assumption  by  Baumgarten  that  tuberculosis  in  the  children  of 
tuberculous  mothers,  even  when  originating  years  after  birth,  is  the 
result  of  an  intra-uterine  invasion,  the  bacilli  remaining  latent  until 
the  conditions,  suitable  for  pathogenic  action  arise,  is  not  regarded  as 
susceptible  of  proof.  It  is  true  that  Harbitz  found  animal-virulent 
bacilli  latent  in  the  lymph  nodes  of  children,  the  nodes  being,  so  far 
as  determined,  normal  in  strncture,  but  the  determination  of  the  pos- 
sible duration  of  such  latency  is  most  difficult,  because  of  the  many 
chances  for  postnatal  invasion. 

Whatever  the  primary  point  of  entrance,  the  original  localization 
of  the  bacilli,  in  the  majority  of  the  cases,  occurs  either  at  the  point 
of  entry  or  in  some  group  of  the  regional  lymph  nodes,  most  frequently 
the  nearest.     It  is  generally  accepted  that  infection  of  the  lymph  nodes 

'  So  far  as  now  known,  there  are  no  anatomic  characteristics  that  enable  one  to 
distinguish  between  hiunan  tuberculosis  due  to  human  bacilli  and  that  due  to 
bovine  bacilli. 


POINTS   OF    ENTRANCE   AND   PRHIARY    LOCALIZATION  61 

cau  take  })lae(^  withoni  leaving  any  recognizahle  Iraee  at  the  point  of 
invasion  of  the  tissues.  Judging  from  the  frequency  of  what  is 
regarded  as  primary  localization  of  tuberculosis,  the  most  suitable 
organs  in  the  body  are  the  lungs  and  the  lymph  nodes.  This  appar- 
ent susceptibility  may  be  due.  in  large  measure,  however,  to  the  rela- 
tively great  frequency  with  which  these  organs  are  exposed  to  infection, 
but  the  localizations  in  hematogenous  infections  also  point  to  the 
aflfinity  of  the  tubercle  ])acillus  for  these  organs.  The  lymph  nodes  in 
question  are  essentiall}'  those  connected  immediately  with  the  digestive 
tract  (tonsils,  cervical,  mesenteric,  retroperitoneal)  and  with  the  respir- 
atory tract.  According  to  recent  investigations,  the  lymph  nodes  are 
by  far  the  most  frequent  points  of  primary  tuberculous  localization 
in  children  (under  fifteen).  Harbitz,  who  has  studied  this  question 
minutely,  groups  his  cases  as  follows : 

Primary  in  the  respiratory  tract 41.0  per  cent. 

Primary  in  the  digestive  tract 22.0        '• 

Primary   in    the   respiratory   or   digestive 

tract   20.5        " 

(Jeneral  lymph-node  tuberculosis,  doubtful 

cases,  etc 10.2        " 

In  the  intestinal  cases  there  may  be  primary  intestinal  ulcers.  On 
account  of  the  ease  with  which  tuberculosis  may  spread  in  the  lymph- 
vascular  sy.stem  of  children,  on  account  of  likelihood,  in  many  cases, 
of  hemaiogenous  infection  of  lymph  nodes,  and  on  account  of  the  pos- 
sibility of  simultaneous  infection  of  different  nodes,  it  is  not  at  all  an 
easy  matter  to  make  a  correct  interpretation  of  many  of  these  cases. 
As  regards  the  respiratory  group  of  cases,  it  naturally  lies  closest  at  hand 
to  assume  an  air  infection,  but  descending  infection  from  the  cervical 
nodes  and  ascending  infection  from  the  abdominal  nodes  frequently 
cannot  be  excluded. 

It  may  be  suggested  that  primary  tul)erculosis  of  the  lymph  nodes 
connected  with  the  digestive  tract  (cervical  and  abdominal)  does  not 
at  all  necessarily  mean  infection  with  bovine  bacilli,  because  there  is 
often  abundant  opportunity,  especially  in  children,  for  contamiiuition 
of  the  food  and  the  mouth  directly  with  tuberculous  material  of  human 
source.  It  is  highly  interesting  to  note  that  in  children  tuberculous 
infection  of  the  lungs  probably  most  commonly  results  from  the  rupture 
of  foci  in  the  bronchial  nodes  into  a  large  bronchus,  generally  near  the 
hilus,  and  a  consecutive  caseous  bronchopneumonia  often  with  dissemi- 
nation to  other  organs. 

Primary  tuberculosis  of  the  lymph  nodes  also  undoubtedly  occurs  in 


62  TUBERCLE   AND   MORBID   ANATOMY 

the  adult,  and  careful  post-mortem  observations  by  Lubarsch,  Harbitz, 
and  others  indicate  that  in  a  certain  percentage  of  cases  of  adult  tuber- 
culosis (5.9  Hof,  6.3  Lubarsch,  7.7  Harbitz)  the  primary  localization 
takes  place  in  the  digestive  tract,  especially  the  intestine. 

Active  discussion  and  investigation  is  now  going  on  as  to  the  rela- 
tive frequency  of  primary  and  secondary  localization  of  tubercle  bacilli 
in  the  production  of  pulmonary  tuberculosis,  the  question  having  been 
raised  by  von  Behring,  Eibbert,  and  others  whether  ])ulmonary  tuber- 
culosis in  adults  cannot  be  traced  to  some  remote  tubercidous  process 
that  existed  long  before — e.  g.,  in  the  lymph  nodes  in  childhood.  At 
the  present  time  the  general  opinion  seems  to  be,  however,  that  while 
the  hematogenous  and  lymphogenous  origin  of  instances  of  nonmiliary 
pulmonary  tuberculosis  cannot  be  denied,  the  disease,  in  the  large  major- 
ity of  the  cases,  originates  from  a  primary,  air-borne  infection  of  the 
lungs  (Schmorl,  "01-02). 

The  most  significant  anatomic  evidences  in  favor  of  the  old  view 
are  that  the  oldest  lesions  generally  are  found  in  the  lungs,  and  that 
in  favorable  cases  it  is  possible  to  demonstrate  the  apparent  primary 
point  of  invasion — ^namely,  a  subepithelial  tuberculous  infiltration  in  the 
wall  of  a  bronchus  of  medium  caliber,  or  a  tuberculous  pneumonia  or 
bronchopneumonia  with  peribronchial  tubercle.  Birch-Hirschfeld  ('99), 
who  made  special  investigation  of  this  point,  found  what  he  considered 
as  the  primary  lesion  most  often  in  the  right  ramus  apicalis  posterior. 
It  is  evident,  however,  that  even  these  lesions  may  result  from  the  depo- 
sition in  the  vessels  in  the  area  concerned  of  l)aci]li  by  the  blood.  Auiong 
the  reasons  assigned  for  the  peculiar  predisposition  of  the  apical  parts 
to  tuberculous  localization  are  poorer  nourishment  of  these  parts,  espe- 
cially at  the  time  of  puberty,  because  the  corresponding  part  of  the 
chest  then  takes  only  small  part  in  the  respiratory  movements.  It  is 
also  held  that  at  the  apex  the  bronchi  branch  at  such  angles  that  obstruc- 
tion easily  occurs. 

DISSEMINATION   OF  TUBERCULOSIS  WITHIN  THE   INFECTED 

BODY 

In  its  beginning  tuberculosis  is  always,  or  practically  always,  a  local 
disease.  So  far  as  known  at  present  the  actual  primary  infection  under 
natural  circumstances  depends  on  the  entrance  and  deposition  in  the 
tissues  of  a  few  bacilli  from  without.  The  sources  of  the  bacilli  and 
the  various  routes  of  entrance  are  discussed  fully  elsewhere.  Now,  what- 
ever the  point  of  invasion,  primary  local  tu])erculosis  is  likely  at  any 
time  to  become  the  source  of  secondary  or  metastatic  tuberculosis.  Most 
commonly  the  bacilli  are  carried  by  the  lymph  vessels,  either  free  or 


DISSEMIXATK^X   WITIIIX   THE   INFECTED   BODY  63 

within  leucocytes.  Cousequeiitly,  iyiuph  nodes  draining  regions  contain- 
ing tuberculous  foci  frequently  become  the  seat  of  secondary  tubercu- 
losis from  the  arrest  Avithin  them  of  bacilli  brought  by  the  lymph 
stream. 

Progressive  local  tuljeiculosis  usually  is  maiked  by  the  development 
of  tubercles  in  the  lymph  channels  in  the  neighborhood,  as  shown  very 
well,  for  instance,  in  the  serous  covering  over  tuberculous  intestinal 
ulcers,  about  tuberculous  foci  in  the  lungs  and  elsewhere.  And  from 
one  group  of  lymph  nodes  tuberculosis  may  spread  by  direct  and  retro- 
grade transport  both  upward  and  downward  to  neighboring  groups,  until 
extensive  chains  of  nodes  are  involved. 

When  this  occurs  in  the  cervical,  tly^racic,  and  abdominal  lymph 
nodes,  as  happens  in  children  in  whom  lymphatic  invasion  appears  to 
occur  with  great  ease,  then  it  may  be  impossible  to  form  any  definite 
conclusion  as  to  whether  the  primary  infection  took  place  in  the  res])ir- 
atory  or  in  the  digestive  tract.  Harbitz  considers  it  likely  that  in 
children  tuberculosis  of  the  lungs  often  develops  as  the  result  of  retro- 
grade transport  from  the  tracheobronchial  lymph  nodes,  because  he 
found  tuberculosis  in  these  nodes  frequently  without  involvement  of  the 
lungs,  but  the  reverse  only  rarely.  Tuberculosis  of  the  mesenteric,  retro- 
peritoneal, thoracic  lymph  nodes,  of  the  pleura,  and  of  the  peritoneum 
may  lead  to  tuberculosis  in  the  thoracic  duct  (first  described  by  Astley 
Cooper,  and  then  by  Ponfick),  from  which  bacilli  may  pass  into  the 
general  circulation,  and  thus  become  distributed  in  greater  or  smaller 
numbers  to  various  parts  of  the  body,  with  the  subsequent  development 
of  acute  or  more  chronic  generalized  tuberculosis.  Indeed,  tubercle 
bacilli  have  been  found  in  the  lymph  from  the  thoracic  duct  in  certain 
cases  in  which  there  was  no  tulierculosis  of  the  duct  itself,  showing  that 
bacilli  were  being  disseminated  from  parts  drained  Ijy  the  duct. 

In  connection  with  the  thoracic  duct  may  be  mentioned  the  highly 
interesting  experiments  of  Pavenel  and  others,  in  which  indications  were 
obtained  that  bacilli  introduced  with  the  food  into  the  stomach  may 
pass  into  the  thoracic  duct  and  become  localized  in  the  lungs,  without 
necessarily  leaving  any  trace  in  the  form  of  lesions  in  the  intestinal 
tract  or  elsewhei-e  that  they  had  taken  this  route.  While  there  is  no 
evidence  that  this  mode  of  infection  ])lays  an  irnportant  role  in  human 
beings,  the  possibility  that  tubercle  bacilli  may  become  localized  at  ])oints 
more  or  less  remote  from  the  point  of  penetration  into  the  tissues,  and 
thus  set  up  lesions  tiiat  may  become  the  center  for  other  more  or  less 
remote  foci,  indicates  the  great  diflficulties  that  may  be  encountered  in 
the  efforts  to  determine  the  route  of  entrance  by  anatomic  methods  of 
investigation. 

Tubercle   bacilli   mav  reach   the   blood   also  as  the  result  of  direct 


64  TUBERCLE  AND  MORBID  ANATOMY 

tuberculous  invasion  of  the  walls  of  Mood-vessels  and  the  discharge  of 
bacilli  directly  into  the  Mood  stream    (see  Miliary  Tuberculosis). 

Dissemination  of  bacilli  within  the  infected  body  takes  place  also 
by  way  of  mucous  and  serous  membranes.  The  routes  of  secretion  and 
excretion  are  important  means  for  the  spread  of  tubercle  bacilli  to  the 
outside  of  the  body  as  well.  Thus,  the  discharge  of  a  disintegrating 
tuberculous  focus  in  the  lung  or  of  peribronchial  lymph  nodes  into  the 
bronchi  may  result  in  the  conveyance  of  bacilli  not  only  to  the  outside 
of  the  body,  but  also  to  various  parts  of  the  respiratory  tract,  as  well 
as,  by  swallowing  the  sputum,  to  the  digestive  tract,  where  secondary 
localizations  in  the  intestinal  lymph  follicles  often  occur.  Jn  this  way 
instances  of  primary  infection, of  the  peribroncliial  nodes,  for  example, 
may  give  rise  to  acute  tuberculous  bronchopneumonia.  In  the  case  of 
the  urinary  tract,  the  breaking  down  of  tuberculous  masses  in  the  kid-, 
ney  may  cause  widespread  infection  of  the  pelvis,  ureter,  and  bladder. 

Finally,  the  entrance  of  bacilli  into  a  serous  cavity  from  some  focus 
adjacent  is  often  the  cause  of  diffuse  and  acute  tuberculous  inflamma- 
tion. In  the  case  of  the  pleura  and  the  pericardium,  general  tubercu- 
losis may  arise  either  from  tuberculous  pulmonary  foci  or  from  foci  in 
the  thoracic  lymph  nodes.  Peritoneal  tuberculosis  often  takes  its  origin 
in  caseous  lymph  nodes,  tuberculous  intestines,  and,  in  the  female,  in 
tuberculosis  of  the  genital  organs.  In  all  these  cases  the  bacilli  are 
distributed  by  movements  on  the  part  of  the  walls  and  the  contents  of 
the  cavities  in  question.  In  the  leptomeninx  the  bacilli  also  spread 
rapidly. 

Inasmuch  as  the  bacillus  of  tuberculosis  does  not  possess  the  rapid 
power  of  growth  in  the  body  that  characterizes  th.e  microbes  of  the 
typical  acute  infectious  diseases,  the  acute  manifestations  of  tubercu- 
losis— acute  miliary  tuberculosis,  acute  tuberculous  pneumonia,  and 
acute  tuberculosis  of  serous  membranes — all  result  from  the  more  or 
less  sudden  or  rapid  dissemination  of  masses  of  bacilli  that  have  accu- 
mulated in  some  preexisting  focus.  So  far  as  we  know,  that  is  the  only 
wa}^  in  which  acute  human  tuberculosis  arises  under  natural  conditions. 

ACUTE    GENERAL    MILIARY    TUBERCULOSIS 

Acute  miliary  tuberculosis,  in  which  innumerable  tubercles  develop 
in  various  parts  of  the  body  at  about  the  same  time,  is  now  universally 
held  to  result  from  the  introduction  into  the  circulation  of  large  num- 
bers of  tubercle  bacilli,  either  at  one  time  or  at  frequent  intervals.  It 
is  regarded  as  a  secondary  infectious  disease.  A  primary  form  is  not 
recognized.  It  is  most  frequently  observed  in  connection  with  pul- 
monary and  lymph-node  tuberculosis,  but  it  may  occur  secondarily  to 


ACUTE   GENERAL   MILIARY  TUBERCULOSIS  65 

tuberculosis  of  bones  and  joints,  of  the  pleura,  pericardium  or  perito- 
neum, of  the  adrenal,  urogenital  organs,  etc. 

The  modern  conception  of  the  nature  and  genesis  of  general  miliary 
tuberculosis  takes  its  origin  in  the  remarkable  statement  by  Buhl  ('72) 
that  miliary  tuberculosis  is  an  infectious  and  resorption  disease,  the 
miliary  nodules  having  the  same  relation  to  the  caseous  foci  as  the 
metastatic  abscesses  in  pyemia  have  to  the  primary  focus  of  suppuration. 

It  was  reserved  for  Carl  Weigert  to  furnish  the  actual  demonstra- 
tion of  the  manner  in  which  tuberculous  material  may  enter  the  blood, 
namely,  by  the  tuberculous  invasion  of  the  walls  of  blood-vessels  or  of 
the  thoracic  duct.  Older  pathologists  regarded  tlie  blood-vessels  as 
immune  to  tuberculosis,  and  Weigert's  observations  put  an  end  to  this 
theory.  He  first  described  the  extension  of  a  caseous  tuberculosis  in  a 
lymph  node  through  the  walls  of  the  vena  anonyma  ('78),  and  shortly 
afterwards  tuberculous  invasion  of  the  pulmonary  veins. 

Shortly  before  the  discover}'  of  the  tubercle  bacillus,  Weigert  ('82), 
who  in  the  meantime  had  found  tuberculous  foci  in  the  veins  in  ten 
and  in  the  thoracic  duct  in  two  of  three  cases  of  acute  general  miliary 
tuberculosis,  announced  that  a  tuberculous  lesion  of  a  vein  or  other 
vessel  must  fulfill  the  following  conditions  before  it  can  be  regarded  as 
the  source  from  which  the  miliary  tuberculosis  has  sprung: 

1.  The  primary  lesion  must,  by  its  appearance  and  structure  (casea- 
tion, size,  etc.),  prove  to  be  of  greater  age  than  the  miliary  nodules. 

2.  The  tuberculous  focus  must  occupy  a  portion  of  the  wall  of  a 
vein  or  larger  lymph  channel  which  is  patulous. 

3.  The  eruption  of  miliary  tubercles  must  be  of  such  a  character  as 
to  be  only  explainable  by  the  theory  that  a  large  amount  of  tuberculous 
poison  has  entered  the  blood  at  once,  and  that,  in  other  words,  their 
development  has  occurred  in  a  relatively  short  space  of  time. 

4.  The  tuberculous  poison  must  actually  extend  to  the  surface  of  the 
focus;  that  is,  it  must  communicate  with  the  lumen  of  the  vessel.  In 
the  ductus  thoracicus,  where  the  nodules  are  placed  on  the  free  surface 
of  the  vessel  lumen,  this  is  usually  the  case.  In  tlie  compact  foci  of 
tlie  veins — for  instance,  the  pulmonary  veins — at  least  a  portion  of  the 
focus  must  be  softened  or  caseated. 

5.  The  venous  tubercle  must  not  be  located  in  the  portal  S3^stem, 
otherwise  the  tuberculous  poison  would  all  be  deposited  in  the  liver. 

With  the  possible  exception  of  the  fifth  condition,  we  are  not  able 
to  say  that  under  the  circumstances  in  question  the  portal  capillaries 
will  hold  back  all  tubercle  bacilli,  and  on  substitution  for  tuberculous 
poison  of  tubercle  bacilli,  Weigert's  conditions  hold  good  to-day.  Koch 
first  demonstrated  bacilli  in  tuberculous  lesions  of  veins  and  of  the 
thoracic  duct,  and  soon  Weigert  was  able  to  show  their  presence  in  his 
6 


66  TUBERCLE  AND   MORBID   ANATOMY 

own  specimens.  Weigert's  masterly  grasp  of  the  problems  and  liis  brill- 
iant interpretation  of  his  observations  will  always  excite  the  highest 
admiration  of  students  of  tuberculosis.  All  subsequent  investigations 
uphold  his  teachings  in  the  main  points.  The  attempt  by  Wild  ('97) 
to  show  that  general  miliary  tuberculosis  is  the  result,  at  least  in  part, 
of  the  multiplication  of  the  bacilli  in  the  circulating  blood,  which  they 
enter  by  more  or  less  undiscoverable  sources,  has  not  received  any  gen- 
eral support. 

Tuberculosis  of  the  walls  of  blood-vessels  may  develop  in  different 
ways.  Direct  extension  may  take  place  from  adjacent  tul)erculous  foci 
or  the  process  may  be  started  by  single  or  multiple  metastasis  on  the 
vascular  intima  or  in  the  wall  itself,  and  rarely  on  the  endocardium. 
Several  instances  of  intimal  aortic  tuberculosis  have  been  described  as 
due  to  the  implantation  of  tubercle  bacilli  (Blumer,  '99),  and  Benda 
considers  this  the  more  frequent  mode  of  origin  of  the  vascular  tuber- 
culosis that  leads  to  general  dissemination,  but  that  view  is  not  gen- 
erally accepted,  at  least  not  with  respect  to  the  blood-vessels.  Tlie 
extension  of  tuberculosis  from  tlie  neighborhood  may  involve  arteries 
and  veins,  but  the  veins  more  frequently.  The  aorta  has  been  found 
extensively  involved  in  this  manner  also.  Of  blood-vessels,  the  pulmo- 
nary veins  most  often  furnish  the  starting  point  for  miliary  tuberculosis, 
but  the  jugular  vein,  the  suprarenal,  the  vena  cava,  the  dural  sinuses, 
the  vesical  veins,  the  endocardium,  the  aorta,  and  the  pulmonary  artery 
— all  may  play  this  role. 

Recent  investigations  indicate  tliat  tul)erculosis  of  the  thoracic  duct 
possibly  is  the  most  frequent  cause  of  general  miliary  tuberculosis. 
Thus  Benda  ('99),  in  19  cases  found  the  point  of  origin  to  be  the 
thoracic  duct  in  12,  and  Longcope  ('06)  in  19  typical  instances  of  gen- 
eralized acute  miliary  tuberculosis  found  in  14  cases  more  or  less  exten- 
sive tuberculosis  in  the  thoracic  duct,  usually  with  caseous  nodules. 
In  all  of  these  cases  Longcope  noted  that  the  mesenteric,  retroperitoneal, 
or  thoracic  lymph  nodes  were  the  seat  of  chronic  tuberculosis. 

In  order  to  study  the  duct  satisfactorily,  it  must  be  dissected  free 
from  its  beginning  in  the  receptaculum  chyli  to  its  entrance  into  the 
left  subclavian  vein.  Solitary  tubercles  may  occur  in  its  extreme  upper 
part.  It  is  often  difficult  to  determine  the  starting  point  of  the  acute 
generalization  of  tuberculosis,  but  in  the  hands  of  experts  success  has 
been  achieved  in  as  high  as  ninety-five  and  even  one  hundred  per  cent. 

Naturally  it  may  be  difficult  to  determine  that  a  given  focus  of 
tuberculous  vasculitis  really  is  the  point  of  origin,  as  there  may  be  more 
than  one  such  focus  in  the  same  body.  In  case  the  lumen  is  not  closed 
by  proliferation  and  thrombosis,  it  is  easy  to  understand  how  a  tuber- 
culous process  in  a  vascular  wall,  on  caseation  and  disintegration,  may 


ACUTE  GENERAL   MILIARY  TUBERCULOSIS  67 

give  off  tuberculous  material  and  bacilli  into  the  blood  or  lymph,  espe- 
cially since  it  has  been  found  that  tuberculous  masses  projecting  into 
the  lumen  commonly  contain  enormous  numbers  of  bacilli,  often  in 
heaps,  in  the  parts  near  the  current.  Indeed,  it  seems  as  if  those  parts 
which  sometimes  are  rough  and  irregular,  and  sometimes  smooth  from 
fibrinous  deposits,  present  especially  favorable  conditions  for  the  mul- 
tiplication of  the  bacilli.  Generally  the  vascular  tuberculous  masses — 
"  vascular  tubercle  " — appear  as  grayish  yellow  nodular  elevations,  and 
at  times  they  may  be  distinctly  polypoid;  when  the  result  of  extension 
or  erosion  from  without  they  are  connected  with  an  extravascular  tuber- 
culous area. 

The  localization  as  well  as  the  number  of  tubercles  in  miliary  tuber- 
culosis are  subject  to  considerable  variation,  depending  on  the  exact 
location  and  nature  of  the  point  of  invasion  and  on  the  number 
of  bacilli  sent  into  the  circulation.  If  the  primary  focus  is  situ- 
ated in  the  walls  of  a  smaller  artery,  then  the  consecutive  eruption 
of  miliary  tubercles  may  be  confined  largely  to  the  corresponding  capil- 
lary district,  and  we  speak  of  a  local  hematogenous  miliary  tubercu- 
losis. Often  the  position  of  the  original  vascular  focus  ma}^  be  surmised 
from  the  distribution  of  the  tubercles;  this  is  true  especially  of  the 
lungs  in  chronic  pulmonary  tuberculosis  (partial  disseminated  hema- 
togenous miliary  tuberculosis).  But  even  imder  these  circumstances, 
bacilli  may  pass  through  the  nearest  capillary  filter  and  give  rise  to 
scattered  tubercles  in  different  organs  and  tissues,  which  is  not  infre- 
quent. In  the  chronic  generalized  tuberculosis  peculiar  to  children, 
numerous  widely  spread,  large  caseous  foci  are  found,  due  to  dissemi- 
nation of  few  bacilli  by  blood  as  well  as  lymph  vessels.  Naturally  there 
are  all  grades  of  transition  between  these  various  forms. 

In  typical,  generalized,  acute  miliary  tuberculosis  most  of  the  organs 
are  permeated  by  uncountable  tubercles,  but  by  no  means  to  the  same 
degree.  Certain  organs,  by  means  of  mechanisms  that  are  not  under- 
stood as  yet,  appear  to  resist  the  development  in  them  of  miliary  tuber- 
cles, notably  the  pancreas,  the  salivary  glands,  and  the  skeletal  muscles. 
Of  all  the  organs  the  lungs,  the  liver,  the  spleen,  the  kidneys,  and  the 
serous  membranes  are  most  commonly  and  most  extensively  involved 
in  general  miliary  tuberculosis.  The  occurrence  of  chorioidal  tubercles 
is  of  much  clinical  interest.  It  is  noteworthy  that  the  tubercles  occur 
most  numerously  in  the  vicinity  of  the  blood-vessels,  and  intimal  miliary 
tubercles  are  not  uncommon,  especially  in  the  lungs  and  leptomeninx. 

The  tubercles,  while  at  first  glance  of  about  the  same  grade  of  devel- 
opment, as  a  rule  will  be  found  to  vary  in  size  from  minute  grayish 
transparent  points  that  are  barely  visible  to  larger  nodules  with  grayish- 
yellow   or  yellowish-white   centers.      And   on   microscopic    examination 


68  TUBERCLE  AND   MORBID   ANATOMY 

numerous  young  tubercles  will  be  found  that  clearly  could  not  be  recog- 
nized by  the  naked  eye.  On  serous  surfaces — e.  g.,  the  pleura — in  the 
lungs,  and  on  the  surface  of  the  kidney,  they  are  usually  surrounded 
by  an  areola  of  congested  vessels.  In  the  serous  cavities  there  may  be 
more  or  less  exudate  present  when  miliary  tubercles  develop  on  the 
lining. 

The  spleen  is  enlarged;  young  tubercles  are  confounded  easily  with 
the  Malpighian  bodies;  the  tubercles,  however,  are  somewhat  more  pro- 
jecting and  easily  peeled  out  with  the  knife  point ;  caseating  tubercles 
are  easily  distinguished. 

The  liver  also  is  somewhat  enlarged,  and  tubercles  can  be  recognized 
in  the  interlobular  connective  tissue  as  well  as  in  the  interior  of  the 
lobules. 

In  the  kidneys  miliary  tubercles  are  found,  particularly  in  the  cor- 
tical parts  and  often  in  rows.  Occasionally  they  are  confined  to  the 
vicinity  of  a  single  branch  of  the  renal  artery.  Tubercles  on  the  surface 
of  the  kidney  may  form  small  prominences  surrounded  by  injected 
vessels. 

In  the  peritoneum  miliary  tubercles  occur  frequently,  and  especially 
in  the  omentum,  which  may  be  rolled  up  and  retracted.  There  may  be 
peritonitis. 

In  addition,  tubercles  occur  in  the  genital  organs,  lymph  nodes, 
adrenals,  tonsils,  the  thyroid,  the  heart  (pericardium,  myocardium,  endo- 
cardium, especially  of  the  right  ventricle),  the  bone  marrow,  and  rarely 
in  the  stomach  and  in  the  skin.  In  the  meninges,  especially  the  lepto- 
meninx,  miliary  tul)erculosis  gives  rise  to  characteristic  changes. 

Tuberculosis  of  the  pia-arachnoid  occurs  by  preference  at  the  base 
of  the  brain  and  over  the  cervical  spinal  cord.  Sometimes  there  is 
only  slight  turbidity  of  the  membranes,  but  usually  there  is  fibrino- 
purulent  or  gelatiniform  fibrinous  exudate  most  marked  about  the 
Sylvian  fissures,  the  optic  chiasm  and  interpeduncular  spaces.  There  is 
acute  hydrocephalus.  Miliary  granulations  are  seen  especially  about 
and  on  the  middle  cerebral  arteries  and  the  arteries  of  the  anterior  and 
posterior  perforated  spaces.  The  tubercles  may  be  hard  to  see,  and  it  is 
best  to  spread  the  membranes  on  a  glass  plate.  Large  or  caseous  nodules 
are  often  present  and  the  inflammation  extends  into  the  brain  tissue 
(meningo-encephalitis).  In  tuberculous  meningitis  there  is  an  inter- 
esting endarteritis  with  tubercles  and  diffused  subendothelial  prolifera- 
tion, best  explained  as  due  to  implantation  of  tubercle  bacilli  and  their 
products  from  the  blood.  The  infiltration  often  spreads  into  the  other 
coats,  all  of  which  may  undergo  caseous  and  hyaline  degeneration.  Tu- 
l)erculous  arterial  and  venous  changes  also  are  common  as  the  result 
of  extension  from  without. 


MORBID  ANATOMY  OF  PULMONARY  TUBERCULOSIS 


69 


THE  MORBID  ANATOMY  OF  PULMONARY  TUBERCULOSIS 

In  the  lungs  tuberculosis  produces  a  complex  variety  of  anatomic 
alterations,  depending,  on  the  one  hand,  on  the  mode  of  invasion,  and 
on  the  other  on  the  number  and  the  relative  virulence  of  the  infecting 
bacilli,  as  well  as  on  the  kind  of  resistance  offered  by  the  infected  body. 


Fig,  6. — Tuberculous  Pneumonia  and  Conglomerate  Tubercles.  (.4)  Spots 
of  tuberculovis  pneumonia.  {B)  Single  tuberculous  air  vesicles  and  groups. 
Early  stage  of  process.  (From  Holt  "  Diseases  of  Infancy  and  Childhood," 
1908.) 

The  anatomic  pictures  presented  by  pulmonary  tuberculosis  consist  of 
miliary  and  larger  nodules,  pneumonic  and  l)ronchopneumonic  areas, 
with,  on  the  one  side,  caseous  softening  with  ulceration  and  cavity 
formation,  and  on  the  other  the  production  of  fibrous  tissue,  cicatriza- 
tion and  limitation.     (Fig.  6.) 

According  to  the  accepted  modes  of  entrance  of  tubercle  bacilli  into 


70  TUBERCLE  AND   MORBID  ANATOMY 

the  lungs,  it  is  customary  to  speak  of  hematogenous,  lymphogenous,  and 
aerogenous  pulmonary  tuberculosis.  When  acute  and  typical  there  is 
no  difficulty  in  the  recognition  from  anatomic  appearances  of  the  first 
two ;  all  three  modes  of  invasion  may  lead  to  the  common  manifestations 
of  tuberculosis  of  the  lungs  in  the  clinical  sense,  and  in  well-established 
cases  it  may  be  difficult  to  determine  from  the  anatomic  lesions  the 
exact  route  of  entrance  into  the  lung. 

Acute  General  Hematogenous  Tuberculosis  of  the  Lungs. — The 
nature  and  origin  of  general  miliary  tuberculosis  have  been  discussed. 
It  remains  to  describe  the  most  striking  appearances  of  the  lungs  in 
this  disease  which  may  appear  in  previously  healthy  lungs  or  in  lungs 
the  seat  of  existing  tuberculosis.  In  either  event,  tubercles  are  found 
in  the  majority  of  the  other  organs  of  the  body. 

The  lungs  on  palpation  are  finely  nodular  or  granular  throughout, 
of  increased  weight  and  consistence,  usually  somewhat  distended.  They 
do  not  collapse  on  section.  The  tissue  is  red  from  congestion,  frequently 
somewhat  edematous,  and  everywhere  permeated  with  tuberculous  nod- 
ules which,  in  many  cases,  gradually  diminish  in  size  from  the  apices 
downward.  Tliese  nodules  are  not  all  miliary  tubercles  in  the  accepted 
sense;  many  are  conglomerations,  and  Orth  especially  has  emphasized 
that  in  miliary  tuberculosis  of  the  lungs  there  spring  up  about  the 
proliferative  nodules,  as  well  as  elsewhere,  pneumonic  and  bronchopneu- 
monic — i.  e.,  exudative,  rapidly  caseating  areas  that  on  gross  examina- 
tion may  appear  as  somewhat  projecting  round  or  angular  nodules. 
This  form  of  inflammatory  reaction  shows  that  the  bacilli  and  products 
may  act  directly  on  the  alveolar  wall  and  reach  the  lumen  even  when  the 
infection  arrives  by  way  of  the  blood.  The  proliferative  tubercles  occur 
mostly  in  the  adventitia  of  the  vessels  of  the  septa,  in  the  perivascular  and 
in  the  peribronchial  tissue.    Tuberculous  endarteritis  is  not  infrequent. 

Often  there  are  areas  of  moderate  emphysema  in  the  lungs  of  miliary 
tuberculosis.  The  reasons  that  the  lesions  in  the  upper  parts  are  far- 
ther advanced  than  in  the  lower  are  not  altogether  clearly  understood. 
It  is  thought  that  the  upper  parts  are  more  vulnerable,  because  they  con- 
tain less  blood  than  the  lower  parts,  and  that  the  bacilli  that  escape  into 
the  alveoli  are  more  easily  removed  as  we  approach  the  base. 

Under  certain  conditions  the  hematogenous  foci  may  be  found  so 
much  enlarged  and  caseous  that  the  condition  is  designated  as  subacute 
or  chronic. 

Pulmonary  miliary  tuberculosis  is  nearly  always  associated  with 
typical  tubercles  on  the  pleura,  which  also  may  show  more  or  less  fibrin- 
ous or  sero-fibrinous  exudate. 

Partial  Disseminated  Hematogenous  Tuberculosis  of  the  Lungs. — 
This  form,  which  is  not  common,  arises  when  bacilli  are  distributed 


MORBID  ANATOMY   OF   PULMONARY  TUBERCULOSIS  71 

by  the  blood  over  a  limited  part  of  the  lungs.  It  usually  arises  in  the 
course  of  existing  tuberculosis  in  the  lungs  from  tuberculous  erosion  of, 
or  the  breaking  down  of,  intimal  tubercles  upon  some  branch  of  the 
pulmonary  artery.  One  reason  for  its  infrequence  is  the  fibrous  narrow- 
ing and  occlusion  of  many  vessels  in  chronic  pulmonary  foci.  Natu- 
rally, single  foci  can  arise  from  the  lodgment  in  the  lungs  of  few  bacilli 
brought  in  the  blood  from  tuberculous  areas  elsewhere,  and  such  metas- 
tatic foci  may  become  the  starting  point  of  chronic  pulmonary  tuber- 
culosis. 

Localized  Pulmonary  Tuberculosis. — The  minute  early  steps  in  the 
evolution  of  local  pulmonary  tuberculosis  may  be  traced  somewhat  as 
follows :  Assuming  the  bacilli  to  be  inhaled,  lodgment  may  take  place 
either  on  the  wall  of  a  small  bronchus  or  in  the  alveoli  (in  either  case 
usually  near  the  apex).  In  the  first  instance  a  bronchial  tubercle  may 
result,  followed  by  gradual  extension  and  caseation,  until  the  wall  is 
converted  into  a  partial  or  complete  caseous  ring.  Caseous  matter  and 
mucus  will  accumulate  in  the  lumen,  and  in  consequence  the  corre- 
sponding alveoli  may  collapse,  and  if  not  rendered  tuberculous,  indura- 
tion can  result. 

From  the  bronchial  focus  the  process  can  extend  outward  into  the 
peribronchial  tissue  and  adjacent  alveoli,  where  desquamated  epithelial 
cells  and  lymphocytes  accumulate  at  the  same  time  as  fibrin  is  precipi- 
tated; in  brief,  a  pneumonic  or  bronchopneumonic  area  develops  in 
which  caseation  soon  takes  place.  In  the  meantime  the  blood-vessels 
in  the  alveolar  walls  become  hyaline,  and  often  the  large  vessels  are 
plugged  by  fibrin,  hence  the  area  becomes  bloodless  and  yellowish- white 
in  color. 

Eadicals  of  the  peribronchial  lymphatics  being  included  in  the  tuber- 
culous district,  the  bacilli  easily  find  their  way  into  the  lymph  vessels, 
and  peribronchial  tuberculous  lymphangitis  results,  the  tubercles  some- 
times running  around  the  bronchi  like  a  string  of  beads,  and  now  exten- 
sion may  take  place  to  the  bronchial  walls  or  to  adjacent  alveoli.  Occa- 
sionally the  process  can  be  followed  as  peribronchial  nodular  cords  clear 
to  the  lymph  nodes  at  the  hilus. 

If  the  bacilli  enter  the  alveoli  directly,  then  a  minute  pneumonic 
focus  may  result,  or  the  bacilli  may  be  carried  by  wandering  cells  into 
the  interstitial  tissue,  there  to  form  tubercles.  In  either  case  the  exact 
mode  of  genesis  would  soon  be  obliterated  because  the  interstitial  tuber- 
cles Avould  soon  lead  to  pneumonic  changes,  and  a  primary  pneumonic 
lesion  would  soon  bo  followed  by  interstitial  processes. 

As  a  rule,  tubercles  with  giant  cells  are  the  more  numerous  the 
slower  the  process,  while  in  rapidly  spreading  pneumonic  exudation,  with 
early  caseation,  tubercles  and  giant  cells  may  be  few  and  even  absent. 


72  TUBERCLE  AND   MORBID   ANATOMY 

Early  stages  of  primary  localization  in  the  mode  here  outlined  are 
not  often  seen  at  autopsies.  Occasionally,  however,  one  finds  that  a 
small  area,  usually  near  the  apex,  may  show  grayish  or  yellowish  gran- 
ules and  areas  either  in  groups  or  more  scattered. 

The  further  fate  of  such  primary  foci  varies.  Healing  by  connective- 
tissue  replacement,  or  encapsulation,  with  calcification,  is  not  uncom- 
mon; but  frequently  the  opposite  occurs — namely,  softening  and  exten- 
sion. If  the  process  involves  a  bronchus  or  bronchiole,  either  primarily 
or  by  extension,  then  the  caseation  may  weaken  the  walls  so  that  it 
dilates  and  the  so-called  bronchiectatic  cavity  results.  Cavities  arising 
from  softening  in  closed  caseous  pneumonic  areas  usually  empty  them- 
selves into  a  bronchus. 

Early  in  the  process  caseous  disintegration  of  the  wall  of  a  bronchus 
may  cause  rupture  of  small  blood-vessels,  and  thus  give  rise  to  the  spit- 
ting of  blood  that  occurs  so  often  in  the  first  stages  of  pulmonary  tuber- 
culosis. 

In"  the  further  progress  of  local  pulmonary  tuberculosis  there  arise 
various  more  or  less  distinct  anatomic  forms,  which  correspond  fairly 
well  to  recognizable  clinical  manifestations  of  the  disease,  according  as 
certain  processes  outlined  in  the  foregoing  predominate. 

Tuherculous  rncuinonia.  —  Cbaracteristic  exudative  pneumonic 
changes  may  develop  at  any  time  in  the  course  of  pulmonary  tubercu- 
losis as  the  result  of  entrance  into  the  alveoli  of  bacilli  or  their  products, 
in  sufficient  quantities  to  cause  exudation  and  immigration.  Tuber- 
culous pneumonia  differs  from  all  other  forms  of  pneumonia  in  that 
the  end  is  caseation.  This  pneumonia  may  vary  greatly  in  its  extent 
and  course  so  that  lobular  or  bronchopneumonic  and  lobar,  as  well  as 
acute  and  subacute  and  chronic  forms,  are  recognized. 

Tuherculous  hroivclio pneumonia  is  the  more  common.  Tt  develops 
oftenest  in  the  lower  lobes  as  the  result  of  aspiration  of  tuberculous 
material  from  cavities  and  older  lesions  into  the  bronchi  and  alveoli,  and 
there  is  usually  a  smaller  or  larger  number  of  areas  of  more  or  less  simul- 
taneous development.  This  form  of  pulmonary  tuberculosis  occurs 
most  frequently  in  children  (after  measles,  whooping  cough,  etc.)  and 
young  persons,  in  whom  it  commonly  assumes  a  rapid  progress.  In 
such  cases  the  peribronchial  lymph  nodes  are  usually  large  and  caseous, 
and  frequently  the  invasion  of  the  lungs  follows  rupture  of  a  tuber- 
culous node  into  a  large  bronchus  near  the  hilus  (Fig.  7).  When  asso- 
ciated with  softening  and  the  production  of  cavities,  in  which  secondary 
infection  may  take  part,  it  constitutes  the  acute  phthisis  or  galloping 
consumption  of  the  clinician. 

In  the  earlier  stages  the  bronchopneumonic  foci  are  grayish-red;  as 
caseation  takes  place  they  become  yellowish  or  whitish,  opaque,  dry  and 


MORBID  ANATOMY  OF  PULMONARY  TUBERCULOSIS     73 


prominent,  granular  on  the  cut  surface.  They  vary  much  in  extent; 
by  fusion  of  contiguous  areas  larger  districts  and  groups  arise,  between 
which  lies  crepitant  lung  tissue  or  a  zone  of  grayish-red,  gelatinous, 
sero-fibrinous  infiltration  (gelatinous  pneumonia),  in  which  proliferation 
and  desquamation  are  comparatively 
slight.  Such  infiltrations  occur  par- 
ticularly about  caseous  districts  that 
are  rich  in  bacilli  and  are  regarded, 
at  least  in  many  cases,  to  re- 
sult from  the  action  of  the 
products  of  the  bacilli.  Ex- 
tensive lesions  occur  without 
the  eruption  of  tubercles,  but 
there  may  be  varying  com- 
binations with  proliferative 
tuberculous  and  fibrous 
changes. 

In  more  chronic  forms 
the  proliferative 
changes  are  more 
marked  and  bacilli  then 
are  found  principally  at 
the  periphery  of  the 
caseous  masses  and 
sometimes  in  large 
heaps.  As  caseation 
extends  the  capillaries 
become  hyaline,  there 
is  more  or  less  oblit- 
erating endovasculitis, 
and  eventually  only  |j 
coal  dust  and  remnants 
of  elastic  tissue  remain 
to  indicate  the  former 
location  of  the  alveolar 
and  bronchial  walls. 
In  case  the  process 
becomes  stationary, 
fibrous  tissue  may  form 

at  the  periphery,  and  in  time  an  encapsulated  fibro-caseous  or  calcareo- 
caseous  mass  may  result. 

Tuberculous  lobar  pneumonia  is  much  less  common.     It  may  result 
from  the  coalescence  of  numerous  bronchopneumonic   areas    (pseudo- 
7 


Fig.  7. — Section  Through  Lung,  Showing  Case- 
ous Tuberculous  Lymph  Glands.  Lung  nor- 
mal.    (From  Northrup.) 


74 


TUBERCLE  AND  MORBID  ANATOMY 


lobar)  or  from  simultaneous  involvement  of  a  whole  lobe  or  even  an 
entire  lung  in  which  there  is  then  an  older  focus,  usually  a  cavity  near 
the  apex,  from  which  inundation  of  the  tissue  with  tuberculous  products, 
formed  and  in  solution,  has  taken  place.  The  affected  parts  are  heavy 
and  airless  and  the  pleura  usually  covered  with  exudate.  Distinct 
tubercles  or  groups  of  tubercles  may  be  recognized  in   places  on   the 


Fig.  8. — Tuberculous  Pneumonia  in  a 
Child  Thirteen  Months  Old.  Ver- 
tical section  through  right  lung.  Up- 
per lobe  caseous  (diffuse  tuberculous 
pneumonia).  Beginning  excavation 
near  center.  Below  simple  pneumo- 
nic consolidation.  Lower  lobe  ap- 
pears normal.  (From  Holt,  "  Diseases 
of  Infancy  and  Childhood,"  1908.) 


Fig.  9. — Cavity  from  Breaking  down 
OF  Tuberculous  Pneumonia.  Same 
lung  as  in  Fig.  8.  Normal  lower 
lobe  shown.     (From  Holt.) 


cut  surface,  which  is  grayish,  gray- 
ish-yellow, or,  in  the  older  parts, 
peculiarly  yellowish- white  and  case- 
ous. Sometimes  a  lobe  and  even 
an  entire  lung  is  caseous,  with  more  or  less  extensive  softening  and 
cavity  formation. 

Ulcerative  Tuberculosis  of  the  Lungs. — This  group  includes  espe- 
cially the  forms  in  which  softening  and  ulceration  are  prominent  features. 
The  lungs  present  a  variety  of  lesions,  including  tuberculous  nodules. 


MORBID   ANATOMY   OF   PULMONARY   TUBERCULOSIS  75 

pneumonic  districts,  caseous  masses,  cavities  of  various  sizes  and  ages, 
and  fibrous  changes.  The  oldest  lesions  usually  are  at  the  apices,  the 
disease  having  progressed  downward,  commonly  more  rapidly  in  one 
lung  than  the  other. 

In  addition  to  aspiration  the  lymph  vessels  take  an  important  part 
in  the  spread  of  chronic  pulmonary  tuberculosis  (peribronchial  and 
perivascular  extension).  In  some  cases,  notably  in  children,  the  mil- 
iary and  larger  nodules  are  distributed  about  the  older  foci  in  a  radial 
manner.  At  other  times  the  dissemination  is  more  scattered.  From 
peribronchial  tubercles  may  arise  caseous,  fibrocaseous,  and  fibrous 
masses  or  by  extension  areas  of  bronchopneumonia.  While  the  primary 
focus  of  lymphogenous  invasion  commonly  is  situated  in  the  lungs 
themselves,  it  may  be  found  also  in  parts  directly  connected  with  the 
lungs,  either  normally  or  as  the  result  of  inflammator}'  processes,  such 
as  lymph  nodes,  ribs,  sternum,  spine. 

T3'pical  bronchopneumonic  areas  develop  in  ulcerative  tuberculosis 
due  to  aspiration  of  the  tuberculous  matter  from  the  older  lesions  into 
the  lower  parts  of  the  lungs.  Such  areas  may  soften  or  become  trans- 
formed into  encapsulated  caseous,  calcareo-caseous,  or  calcareous  masses. 
Smaller  tuberculous  areas,  whatever  their  mode  of  origin,  may  be  found 
surrounded  by  grayish-red  zones  of  pneumonic  exudation.  Tuberculous 
ulcerations  may  be  found  in  the  mucous  membrane  of  the  larger  bronchi. 
Bronchiectasis  is  often  present. 

The  cavities  are  a  distinguishing  feature  of  this  form  of  pulmonary 
tuberculosis.  They  arise  because  physical  and  chemical  changes  lead  to 
the  softening  of  the  caseous  substance  into  a  thick  suspension  not  unlike 
pus.  More  frequently  this  begins  in  the  wall  of  a  diseased  bronchus 
which  becomes  more  or  less  dilated.  The  detritus  contains  fragments 
of  dead  cells,  elastic  fibers,  and  usually  numerous  bacilli.  Smaller  cavi- 
ties by  extension  may  coalesce,  and  in  a  short  time  large  excavations 
result  in  acute  cases.  Breaking  dowm  may  occur  also  in  the  center 
of  a  closed  caseous  area;  in  this  case  communication  with  a  bronchus 
becomes  established  later. 

The  size  and  form  of  a  cavity  depend  originally  on  those  of  the 
focus  in  which  it  originates.  If  in  a  caseous  peribronchial  nodule  or 
in  a  small  bronchopneumonic  area,  then  the  cavity,  at  least  at  first,  is 
small,  circumscribed.  In  large  areas  of  caseous  pneumonia,  spots  of 
softening  may  coalesce,  and  there  may  form  irregular  caverns  without 
definite  walls.  In  acute  progressive  cases  one  or  more  lobes  may  be 
more  or  less  excavated  in  a  short  time.  In  the  chronic  ulcerative  tuber- 
culosis there  are  older  cavities  with  definite  Avails  in  the  upper  lobes, 
while  lower  down  may  be  more  recent  ones  without  any  definite  limit- 
ing membrane.     In  older  cavities  a  more  or  less  distinct  wall  or  mem- 


76 


TUBERCLE  AND  MORBID  ANATOMY 


brane  is  present  from  which  pus  is  discharged;  by  necrosis,  and  by 
caseation  of  tuberculous  foci  in  the  adjacent  tissue,  gradual  extension 
is  effected.     Extremely  large  cavities  may  result.     On  the  inner  surface 


Fig.  10. — Tuberculosis  of  Eleven  Years'  Standing.  Resident  of  Colorado  one 
month.  Right  hmg  shows  cavity  the  size  of  a  small  orange  at  apex  with  ex- 
tensive consolidation.     (Dr.  J.  A.  Wilder's  case,  Denver.) 

of  older  cavities  are  bands  and  irregular  projections,  the  remnants  of  the 
framework  in  which  traces  of  bronchi  and  vessels  may  be  recognized. 
(Fig.  10.) 

Occasionally  minute  aneurysms  (1  to  3  mm.)  form  on  the  exposed 
branches,  rupture  of  which  is  one  cause  of  the  hemorrhage  of  ulcerative 
tuberculosis.  More  frequently  the  larger  hemorrhages  result  from  ero- 
sion by  caseation  of  suppuration.  Decomposition  of  the  contents  of 
cavities  may  be  followed  by  gangrene.  In  quiescent  cavities  the  wall 
is  cicatricial  and  the  inner  surface  has  a  smooth  lining.  The  neigh- 
borhood is  then  usually  fibrous,  and  shrinking  may  have  occurred  to 
the  extent  that  smaller  cavities  are  obliterated  or  reduced  to  fistulous 
passages.  At  the  apex  pleural  adhesions  usually  prevent  obliteration  of 
large  cavities. 

The  pleura  is  usually  fibrous  over  old  cavities  and  firm  adhesions 
are  the  rule,  especially  abo^^t  the  apices,  and  thus  rupture  of  cavities 
into  the  pleura  is  prevented.  Sometimes  the  fibrous  pleura  contains 
tuberculous  nodules,  and  exudative  pleuritis  is  not  infrequent.  Rarely 
cavities  rupture  externally  at  the  point  of  pleural  adhesions ;  fresh, 
usually  small,  cavities  in  the  upper  lobes  or  suppurating  cavities,  situ- 


MIXED   INFECTION   IN   PULMONARY  TUBERCULOSIS  77 

ated  closely  to  the  pleura,  may  rupture  into  the  pleural  sac.  The  open- 
ing may  be  very  minute.  The  usual  immediate  consequence  is  entrance 
of  air  into  the  chest  cavity,  on  which  follows,  as  a  rule,  suppuration 
(pyopneumothorax).  The  peribronchial  lymph  nodes  are  usually  tuber- 
culous; in  chronic,  stationary,  or  healed  cases  often  calcified. 

Tuberculous  changes  are  frequent  in  other  regions,  and  first  of  all 
in  the  larynx  and  intestines,  in  which  they  result  from  surface  infection 
by  bacilli  from  the  lungs.  The  pericardium  may  be  involved  by  exten- 
sion. Acute  and  chronic  hematogenous  tubercles  may  be  found  in  the 
spleen,  kidneys, 'brain,  liver.  The  spleen,  liver,  kidneys,  and  intestinal 
mucus  are  often  the  seat  of  amyloid  changes,  and  the  liver  is  frequently 
fatty. 

MIXED    INFECTION    IN    PULMONARY    TUBERCULOSIS 

The  variety  of  lesions  in  ordinary  pulmonary  tuberculosis  long  ago 
suggested  the  question  whether  in  reality  several  simultaneous  or  super- 
imposed diseases  were  not  concerned.  While  Laennec  favored  strongly 
the  view  that  all  the  lesions  were  tuberculous,  Virchow  held  that  the  tu- 
bercle and  the  caseous  pneumonic  foci  were  different  processes  etiologi- 
cally.  This  question  of  the  unity  or  duality  of  the  chronic  pulmonary 
tuberculous  (phthisical)  process  was  settled  finally  in  favor  of  Laennec's 
view,  when  it  became  possible,  as  a  result  of  the  discovery  of  the  tuber- 
cle bacillus,  to  demonstrate  the  etiologic  unity  of  tubercle  and  of  caseous 
pneumonia.  While  the  studies  of  Orth  ("07),  Frankel  and  Troje  ("94), 
and  others  leave  no  doubt  as  to  the  correctness  of  this  conclusion,  the 
part  played  by  secondary  infection  in  pulmonary  tuberculosis  merits 
consideration. 

The  actual  investigations  (Sata,  "99;  Ophiils,  "00).  as  to  the  con- 
ditions in  the  lungs  in  more  or  less  advanced  pneumonic  and  ulcerative 
tuberculosis,  have  shown  that  secondary  mixed  infection  is  a  frequent 
event.  Thus  in  Sata's  21  cases  actual  mixed  infection — that  is,  invasion 
by  bacteria  of  the  walls  of  cavities  or  the  interior  of  bronchopncumonic 
foci,  either  alone  or  in  conjunction  with  tubercle  bacilli — was  estab- 
lished in  12  (streptococci  predominated  in  6,  pneumococci  in  4.  staphy- 
lococci in  1 ;  among  other  bacteria  were  colon  and  pseudodiphtheria 
bacilli).  Of  26  cavities  examined  by  Ophiils,  7  contained  the  tubercle 
bacillus  only;  in  the  others  were  mixtures  of  bacteria  (the  streptococcus, 
pneumococcus,  and  pseudodiphtheria  bacilhis  predominating). 

Undoubtedly  mixed  infection  may  occur  from  the  beginning;  it 
may  cause  areas  of  bronchopneumonia  and  promote  disintegration  of 
caseous  material  and  the  formation  of  cavities.  Prudden  ("94)  showed 
that  in  rabbits  with  caseous  pneumonic  areas,  intratracheal  injections 


78  TUBERCLE  AND  MORBID  ANATOMY 

of  streptococci  were  followed  by  rapid  softening  and  formation  of  cavi- 
ties. Or  the  infection  may  take  place  after  softening  in  purely  tuber- 
culous areas  and  open  a  communication  with  the  bronchi.  Naturally 
such  foci  constitute  favorable  soil  for  bacteria  other  than  tubercle 
bacilli;  vegetating  here,  their  products,  on  absorption,  producing  toxic 
effects;  they  also  may  enter  the  walls  of  the  cavities  or  be  carried  with 
other  contents  to  other  parts  of  the  hmgs,  in  either  case  setting  up  foci 
of  inflammation  with  more  or  less  constitutional  disturbances. 

It  lies  close  at  hand  to  assume  that  invasion  of  the  blood  often  takes 
place  from  the  foci  of  mixed  infection  in  the  lungs,  but  on  account  of 
other  possibilities  no  final  conclusions  may  be  drawn.  In  50  cases  in 
which  Teissier  ('01)  examined  the  blood  bacteriologically  during  periods 
of  hectic  fever,  streptococci  or  staphylococci  were  recovered  in  9. 

FIBROID,  QUIESCENT,  AND  HEALED  TUBERCULOSIS  OF  THE 

LUNGS 

Limiting  and  indurative  processes  are  encountered  in  various  stages 
and  forms  in  pulmonary  tuberculosis.  Frequently  the  earliest  foci  in 
the  apices  show  extensive  fibrous  change,  and  scattered  bronchopneu- 
monic  as  well  as  peribronchial  foci  may  undergo  fibrous  transformation 
and  heal,  with  or  without  calcification.  Occasionally  in  the  case  of 
somewhat  larger  foci  the  central  part  becomes  fibrous  and  hard,  while 
small  caseating  nodules  are  scattered  about  at  the  periphery,  the  whole 
resembling  somewhat  a  rosette  with  sunken  center. 

When  the  fibrous  process  is  extensive  the  condition  usually  corre- 
sponds to  the  so-called  fibroid  tuberculosis  (tuberculo-fibroid  phthisis), 
which  may  supervene  on  either  the  ulcerative  or  the  more  definite 
bronchopneumonic  form  of  tuberculosis.  In  either  case  there  is  usually 
a  cavity  or  a  series  of  cavities  in  one  apex,  surrounded  by  dense  fibrous 
tissue,  with  more  or  less  extensive  induration  of  the  surrounding  dis- 
tricts. The  corresponding  pleural  cavity  is  largely  or  completely  oblit- 
erated by  firm  adhesions,  bands  passing  inward  into  the  various  parts 
of  the  lung,  in  which  there  is  more  or  less  extensive  and  diffuse  or  more 
nodular  (bronchopneumonic)  fibrous  changes,  wdth  here  and  there  scat- 
tered caseous  areas.  Usually  there  is  some  active  tuberculosis  some- 
where in  the  lungs.  The  scar  tissue  in  the  lungs  may  compress  the 
bronchi  so  that  areas  of  alveoli  collapse,  to  be  followed  by  a  persistent 
edema  or  by  progressive  induration.  The  unaffected  parts  of  the  lung 
tissue  may  be  emphysematous. 

A  tuberculous  process  may  be  regarded  as  healed  only  when  there 
has  formed  a  more  or  less  structureless  connective  tissue  with  or  without 
calcareous  deposits  but  without  caseous  material.     Caseous  foci,  though 


TUBERCULOSIS   OF   THE   LUNGS  79 

evidently  old,  partly  calcified,  and  encapsulated,  may  contain  animal 
virulent  bacilli  (Bugge).  Quiescent  or  healed  tuberculous  areas  are 
found  most  commonly  in  the  apices.  There  may  be  nodular  encapsu- 
lated masses  containing  caseous  or  more  puttylike  material,  often  cal- 
careous, over  which  the  pleura  is  retracted  or  corresponding  to  which 
there  is  adhesion.  Microscopically  the  process  may  be  clearly  at  a  stand- 
still, the  capsule  being  composed  of  fibrillary  or  hyaline  tissue  and 
fibrous  tubercles  may  be  scattered  about.  Occasional  fresh  tubercles 
are  seen. 

Anatomically  areas  of  healed  tuberculosis  oftenest  appear  as  slaty 
indurations,  usually  apical  and  subpleural,  flat  or  nodular,  with  retrac- 
tion or  adhesion  of  the  pleura,  and  inclosing  small  calcareous  masses, 
fibroid  tubercles  perhaps  being  present  in  the  adjacent  tissue.  Mere 
slaty  indurations  are  not  sure  signs  of  healed  tuberculosis,  as  they  may 
arise  from  inhaled  dust,  in  the  healing  of  infarcts,  and  after  non- 
tuberculous  pneumonia.  Bugge  found  that  of  138  persons  over  one 
year  of  age  who  died  from  other  causes  than  tuberculosis  in  the  lungs, 
thirty-five  per  cent  presented  changes  that  could  be  interpreted  as  due 
to  healed  tuberculosis. 

At  the  International  Congress  in  Washington  (1908)  Bartel  empha- 
sized that  because  invasion  of  lymph  nodes  by  tubercle  bacilli  may  give 
rise  to  a  lymphocytic  hyperplasia  and  in  some  cases  lead  to  no  apparent 
changes  whatsoever,  it  often  becomes  a  matter  of  great  diflficulty  to 
determine  the  exact  point  of  entry  of  the  bacilli  into  the  body.  In 
other  words,  manifest  typical  tuberculosis  is  not  a  sufficient  basis  for 
the  determination  of  the  point  of  entrance.  Bartel  holds  that  infection 
from  the  pharynx,  stomach,  and  intestines,  especially  early  in  life,  is 
more  frequent  than  generally  believed.  From  post-mortem  observations 
Wollstein  concludes  that  in  infants  and  in  young  children  the  instances 
of  tuberculosis  of  respiratory  origin  are  more  numerous  than  those  of 
digestive  origin. 


CHAPTER   III 

EESISTANCE,    PREDISPOSITION,    AND    IMMUNITY 
By   EDWARD   R.    BALDWIN 

RESISTANCE 

Animals  in  General.— So  far  as  is  known,  no  animal  is  absolutely 
immune  against  tuberculosis,  but  wide  dift'erences  obtain  in  the  sus- 
ceptibility of  different  species.  The  herbivora  are,  as  a  rule,  the  least 
resisting,  the  carnivora  the  most,  while  the  omnivorous  varieties  are 
probably  intermediate  in  this  respect.  Guinea  pigs,  rabbits,  and  cattle 
evince  great  susceptibility  to  bovine  tuberculosis,  while  dogs,  cats,  foxes, 
lions,  tigers,  etc.,  require  larger  doses  or  special  conditions  to  produce 
infection.  On  the  other  hand,  asses,  goats,  horses,  rats,  mice,  and  other 
rodents  are  higlily  resistant,  while  swine,  apes,  and  monkeys  are  very 
susceptible  to  both  human  and  bovine  tuberculosis.  Nearly  all  birds 
are  insusceptible  to  mammalian  tuberculosis,  but  are  very  easily  infected 
with  the  avian  type,  though  the  carnivora  here  also  have  more  resistance. 

Man. — Mankind  forms  no  exception  among  the  animals  by  having  a 
notably  greater  degree  of  resistance  than  other  omnivora,  yet  he  is  less 
easily  infected  than  the  small  herbivora,  and  quite  resistant  in  healthy 
adult  life.  A  greater  difference  would  appear  to  exist  between  indi- 
viduals of  the  human  race  in  their  natural  resistance  than  between  the 
lower  animals  of  the  same  kind. 

It  has  been  an  important  question  to  settle  as  to  the  susceptibility 
of  man  for  the  bovine  type  of  bacillus,  and  the  matter  may  now  be 
considered  determined  that  there  is  no  reason  to  think  that  mankind 
is  less  susceptible  to  it  than  to  the  human  type.  It  is  also  held  to  be 
possible  that  the  avian  bacillus  may  occasionally  infect  human  beings 
(Pansini,  *94 ;  Rabinowitsch,  '04). 

Individual  Resistance. — The  resistance  possessed  by  each  individual 
is  the  chief  object  for  study  in  order  to  arrive  at  a  correct  understand- 
ing of  the  nature  of  man's  defenses  against  this  disease.  It  is  evident 
that  such  defenses  may  be  considered  normal  when  applied  to  a  person 
in  perfect  health  and  of  good  physique,  or  subnormal  if  descriptive  of  one 
who  is  structurally  and  functionally  "  predisposed  "  to  tuberculosis,  in 
the  broad  meaning  of  the  term.  Still  further,  one  may  conceive  of  an 
80 


RESISTANCE  81 

increased  resistance,  either  natural  or  acquired,  and  finally  the  exist- 
ence of  an  actual  immunity.  In  a  problem  of  such  inherent  complexity 
it  is  not  to  be  supposed  that  all  the  factors  constituting  resistance  to 
disease  will  be  considered  here,  but  only  those  especially  applicable  to 
tuberculosis.  It  is,  nevertheless,  true  that  no  other  disease  illustrates 
so  fully  the  import  of  those  principles  of  physiology  that  have  to  do 
with  the  protection  of  life  from  parasitic  enemies. 

•NORMAL  PHYSIOLOGIC   RESISTANCE 

All  clinical  experience  bears  witness  to  the  fact  that  adults  of  good 
physique,  in  functional  and  organic  health,  possess  a  nearly  perfect 
protection  against  natural  infection  by  iubercle  bacilli. 

There  is,  first,  the  external  skin,  which  is  rarely  inoculated  with 
serious  results;  then  the  mucous  membranes,  which  are  amply  protected 
by  ciliated  epithelia,  and  the  mucous  secretions,  which,  when  in  healthy 
condition,  act  mechanically  in  removing  inhaled  or  swallowed  bacilli. 
The  reflexes,  coughing  and  sneezing,  the  normal  digestive  and  vaginal 
secretions  also  act  mechanically  or  chemically  as  protective  agencies. 
To  these  may  be  added  intestinal  peristalsis  and  the  cleansing  effect  of 
the  outward  flow  of  the  tears  and  urine.  While  it  is  very  doubtful  if 
any  of  the  secretions  mentioned  act  strongly  bactericidal  to  the  tubercle 
bacillus  under  natural  conditions,  the  gastric  juice  and  vaginal  mucus 
probably  weaken  it.  It  is  also  questionable  whether  the  epithelia  of  tlie 
lung  alveoli  are  normally  invulnerable  by  the  tubercle  bacillus. 

Influence  of  Age. — The  influence  of  age  is  important  in  connection 
with  resistance  to  tuberculous  infection.  Infants  and  young  children 
are  normally  very  susceptible,  often  in  spite  of  apparent  buoyant  health. 
The  frequency  of  tuberculous  meningitis  among  the  best-developed  and 
healthy  infants  is  testimony  to  this  fact.  Moreover,  the  delicate  epi- 
thelial covering  and  easily  permeable  lymph  spaces  present  but  a  slight 
barrier  to  infection  during  early  childhood,  and  at  birth  the  incomplete 
development  of  the  gastro-intestinal  mucosa  is  made  responsible  by  von 
Behring  ('03)  for  much  infantile  infection  by  means  of  food.  With 
growth  the  resistance  increases  and  attains  its  maximum  between  twenty- 
five  and  fifty,  after  which,  doubtless,  a  second  period  of  relative  sus- 
ceptibility ensues,  though  clinically  less  easily  discernible. 

Influence  of  Heredity. — The  value  of  a  good  vigorous  ancestry  has 
always  been  recognized  in  connection  with  llio  warding  off  of  con- 
sumption, but  a  l)elief  in  its  infallible  protection  has  too  often  led  to 
serious  errors  and  procrastination  among  patients.  In  the  ante-bacillus 
era  the  influence  of  heredity  in  the  direct  causation  of  consumption  was 
considered  paramount  and  nahirally  overestinuited.  The  inheritance 
of  functional  characteristics  which  are  attributes  of  good  health  is  quite 


82  RESISTANCE,   PREDISPOSITION,   AND   IMMUNITY 

as  obvious  as  the  opposite,  and  is  of  great  importance  to  normal  resist- 
ance.    Racial  differences  are  also  to  be  noted  (vide  infra). 

Nature  of  Physiologic  Resistance. — Much  study  and  speculation  have 
been  expended  on  the  processes  of  cellular  resistance  in  relation  to  tuber- 
culosis. No  attempt  to  correctly  interpret  nature's  methods  has  yet 
been  vi^holly  successful,  but  we  may  assume  that  they  do  not  vary  in  es- 
sential features  from  those  employed  to  combat  other  bacterial  infections. 
The  condition  of  the  blood  in  possessing  a  normal  content  of  salts,  nor- 
mal alkalinity,  and  absence  of  an  excess  or  deficiency  of  certain  ingre- 
dients, are  doubtless  factors  of  importance.  Normal  coagulalnlity, 
agglutinating,  opsonifying,  and  bacteriolytic  functions  attaching  to  the 
plasma  are  presumably  of  especial  importance  in  the  localization  and 
destruction  of  tubercle  bacilli,  judging  from  their  lessened  power  in 
the  blood  of  persons  who  lack  resistance.  On  the  other  hand,  no  one 
element  has  proved  a  safe  criterion  of  resistance  thus  far,  although  it 
is  possible  that  the  determination  of  the  opsonic  index,  as  introduced 
by  Wright  and  Douglas  ('04),  of  London,  may  eventually  become  a 
measure  of  resistance  values. 

In  the  last  analysis  all  the  phenomena  of  resistance  depend  on  the 
reactions  of  the  living  cells  of  the  body,  and  here  we  meet  great  dif- 
ficulty in  observing  the  changes  which  accompany  a  successful  struggle 
by  the  tissues  against  the  tubercle  bacillus.  The  polynuclear  leucocytes 
are  first  engaged  in  phagocyting  the  invaders,  but  the  lymphocytes  and 
fixed  cells  evidently  participate  later  in  the  process  of  disintegrating 
the  bacilli.  This  appears  to  take  place,  at  first,  chiefly  in  the  lymph 
nodes  nearest  their  point  of  entrance  into  the  body. 

The  digestive  functions  of  the  various  leucocytes  best  account  for 
the  mechanism  of  resistance,  but  further  than  this  surmises  cannot 
safely  go  at  present.  (A  further  discussion  of  this  subject  as  related 
to  immunity  is  to  be  found  on  page  95.) 

SUBNORMAL    RESISTANCE— PREDISPOSITION 

A  true  predisposition  to  tuberculosis  would  imply  a  specific  lower 
resistance  to  this  infection  in  particular.  This  is,  at  present,  hardly 
more  than  an  hypothesis,  since  in  former  times  many  of  the  indications 
referred  to  as  specific,  such  as  scrofulosis,  later  proved  to  be  actual 
manifestations  of  previously  existing  infection.  In  view  of  this  altered 
conception,  one  may  more  accurately  denote  a  predisposition  as  sub- 
normal resistance  which  may  or  may  not  be  specific,  inherited,  or  ac- 
quired, yet  of  great  practical  importance. 

In  contrast  to  normal  cellular  vigor,  the  cell  functions  may  be  weak 
or  a  deficiency  of  certain  mature  forms  may  exist,  as  found  by  Arneth 
('05)   with  the  leucocytes.     He  discovered  that  polynuclear  cells  con- 


RESISTANCE  83 

taining  a  large  number  of  nuclei  were  diminished  in  persons  in  poor 
health.  Likewise,  Wright  has  found  a  lower  opsonic  index  to  the 
tubercle  bacillus  in  "  predisposed  "  persons.  The  normal  serum  anti- 
bodies, agglutinins,  bacteriolysins,  and  opsonins  are  also  weaker  in  per- 
sons fairly  classed  as  subnormal  in  a  clinical  sense;  hence  the  assump- 
tion that  a  changed  condition  of  the  blood  fluids  has  an  appreciable 
relation  to  lowered  resistance  is  justifiable. 

Much  stress  is  laid  by  Eobin  and  Binet  ('01)  and  other  French 
authors  on  a  deficiency  of  the  calcium  and  magnesium  salts,  and  also 
of  phosphates  in  the  tissues  as  a  result  of  increased  respiratory  activity 
which  produces  a  greater  interchange  of  CO2  and  oxygen.  This  "  de- 
mineralization  "  theory  of  predisposition  is  related  to  others,  such  as 
that  of  Schulz  ('03),  who  finds  the  silicates  in  the  connective  tissue 
lessened  or  variable  in  amount.  Furthermore,  the  degree  of  alkalinity 
of  the  blood,  as  represented  in  the  bronchial  mucus,  is  considered  a  factor 
by  Hesse  ('03)  in  favoring  or  opposing  the  growth  of  tubercle  bacilli. 
The  well-known  susceptibility  of  diabetics  probably  depends  on  the 
excess  of  sugar,  whether  directly  or  indirectly  may  be  an  open  question. 

Chemical  conditions  of  the  tissues  cannot  alone  be  considered  a  suf- 
ficient explanation  of  subnormal  resistance,  however  important  they 
may  be,  nor  is  there  sufficient  proof  of  their  specific  relation  to  the 
tubercle  bacilli. 

Influence  of  Sex. — Females  at  the  time  of  menstruation,  pregnancy, 
and  parturition  are  physiologically  less  resistant;  this  is  also  true  at  tbe 
menopause.  The  evidence  of  such  lowered  resistance  in  females  is  seen 
in  the  development  of  latent  tuberculosis  into  activity  at  these  periods, 
but  with  pregnancy  the  converse  may  often  appear  in  an  arrest  of  a 
previously  active  process.  Analogous  physiologic  changes  in  males  have 
not  been  associated  with  tuberculous  infection. 

Inherited  Predisposition. — The  bearing  of  inherited  weaknesses  on 
the  development  of  tuberculosis  is  apparently  one  of  the  most  unmis- 
takable facts  in  medicine,  but  a  modification  of  former  views  has  been 
inevitable  as  the  role  of  infection  in  early  life  has  become  clearer.  A 
differentiation  has  been  necessary :  first,  between  actual  congenital  dis- 
ease, i.  e.,  transmission  of  the  bacillus  in  utero  (see  Hereditary  Trans- 
mission) ;  and  second,  a  specific  vulnerability  of  the  offspring  after 
birth.  Close  study  has  failed  to  establish  the  exact  role  of  inherited 
disposition  in  this  narrow  meaning,  yet  statistical  and  experimental 
support  has  been  forthcoming.  On  the  one  hand,  there  is  an  apparent 
racial  susceptibility  in  the  Negro  and  Indian  which  cannot  be  described 
as  specific,  since  no  evidence  exists  of  the  prevalence  of  the  disease  in 
former  generations;  while  the  converse  seems  true  of  tbe  Europeans 
and  Anglo-Saxons,  whether  due  to  gradual  immunization  or   by  the 


84  RESISTANCE,   PREDISPOSITION,   AND   IMMUNITY 

elimination  of  the  weaker  individuals,  both  of  which  theories  are  plaus- 
ible. On  the  other  hand,  the  study  of  tuberculous  families  furnishes 
conflicting  evidence  of  transmitted  susceptibility.  J.  E.  Squire  ('97, 
'01)  found  that  in  1,000  families  only  ten  per  cent  more  of  the  chil- 
dren of  tuberculous  parentage  became  tuberculous  than  those  of  non- 
tuberculous  families  in  the  same  class  of  people,  a  difference  easily 
accounted  for  by  the  greater  chance  for  infection  in  the  former.  In 
the  Faroe  Islands  the  people  have  closely  intermarried  and  had  no  out- 
side opportunities  for  infection  for  many  generations,  yet  no  proof  of 
inherited  disease  or  susceptibility  Avas  obtained  by  Boeg  ('05).  Davies 
('00),  however,  finds  the  much  greater  prevalence  of  tuberculosis  on 
the  Isle  of  Man  attributable  to  close  intermarriage,  which  may  or  may 
not  be  interpreted  as  conferring  a  specific  susceptibility.  The  genea- 
logic  tables  of  Eiffel  COG)  and  Leudet  ("85)  are  made  to  support  the 
latter  theory,  but  are  less  conclusive.  From  the  standpoint  of  biologic 
research  Adami  ('04)  and  Hueppe  ('03)  affirm  a  belief  in  transmitted 
specific  vulnerability  on  the  ground  that  the  transmission  of  specific 
immunity  implies  the  opposite  as  a  quality  of  protoplasm  subjected  to 
a  specific  poison. 

Experiments  along  this  line  have  not  been  fruitful  of  results.  From 
the  maternal  side  the  young  of  animals  subjected  to  tuberculous  toxins 
are  said  by  Carriere  ('00)  and  Sicolla  and  Palmieri  ('96)  to  be  more 
susceptible,  yet  it  is  evident  that  pregnant  consumptives  in  the  active 
stages  of  the  disease  are  likely  to  bear  weakling  children  anyway,  and  if 
the  fetus  is  exposed  to  injury  by  the  toxins  it  will  likely  be  a  short- 
lived infant.  When  the  disease  is  not  in  an  active  stage  in  the  mother, 
no  toxic  influence  can  be  assumed  to  play  a  part,  so  that  much  less 
ground  exists  in  such  instances  for  a  specific  inheritance.  Moreover, 
tul)erculin  susceptibility  has  not  been  proven  to  be  transmissible.  On 
the  whole,  a  truly  specific  predisposition  from  maternal  inheritance  has 
no  experimental  basis,  and  from  the  paternal  side  there  is  much  less 
warrant  for  a  belief  in  it. 

Inherited  Structural  Defects. — While  specific  characteristics  refer- 
able to  the  cell  protoplasm  which  constitute  disposition  are  not  readily 
discerned  with  our  present  methods  of  research,  there  are  many  abnor- 
malities of  structure  and  function  which  are  inherited  and  may  be 
acquired,  that  produce  subnormal  resistance  to  tuberculosis  equal  in 
importance  to  any  assumed  specific  disposition. 

The  shape  of  the  chest  formerly  had  more  attention  bestowed  on 
it  than  at  present,  yet  clinical  experience  bears  out  the  old  idea  that 
the  shallow  or  pigeon-chested  individual  has  a  poor  resistance  to  tuber- 
culosis. On  the  other  hand,  Brown  and  Pope  ('04)  found  no  distinctive 
type  in  the  chest  shape  of  patients  in  the  Adirondack  Cottage   Sani- 


RESISTANCE  85 

tarium,  but  who,  as  a  rule,  are  selected  because  of  a  favorable  prognosis. 
They  did  find,  however,  an  average  longer  thorax  than  normal.  Sta- 
tistics of  consumptives  show  about  thirty-five  per  cent  to  have  the 
phthisical  form  of  chest,  yet  this  is  not  enough  to  establish  its  promi- 
nence as  a  factor  in  causation  unless  we  could  exclude  the  cases  in  which 
it  is  secondary  to  the  disease,  a  point  generally  disregarded  in  former 
studies. 

The  habihis  phthisiciis  of  Hippocrates  was  well  recognized  in  olden 
times  as  a  peculiar,  fiat-formed  chest,  with  protruding  scapula,  in  per- 
sons with  long  bones,  delicate  features,  and  blonde  skins.  A  long  neck, 
sloping  shoulders,  and  defective  muscular  development  about  the  chest, 
with  relative  immobility,  were  prominent  features  emphasized  by  Roki- 
tansky  ('46).  Many  years  ago  Freund  ('58)  found  premature  ossifica- 
tion of  the  first  rib  at  the  costosternal  joint  and  shortening  of  the  rib, 
frequently  associated  with  apical  tuberculosis,  and  ascribed  this  to  the 
restriction  of  movement  caused  thereby.  Hart  ("06)  has  recently  elabo- 
rated Freund's  theory  by  an  extensive  pathologic  study,  and  finds  that 
it  has  much  importance  in  causing  a  restriction  of  thoracic  development 
and  function  at  the  apex.  He  considers  it  both  an  inherited  and  ac- 
quired maldevelopment  of  the  costal  cartilage  of  the  first  rib,  which 
leads  to  an  infantile  type  of  apex,  with  proportionally  greater  antero- 
posterior diameter.  Depression  of  the  sternum,  a  restricted  movement 
and  diminished  angle  at  the  junction  of  the  manubrium  and  gladiolus 
(Louis'  angle)  were  associated  with  other  anomalies  by  Rothschild 
('00)  in  causing  a  predisposition  to  lung  tuberculosis,  but  the  studies 
of  Hart  failed  to  confirm  this.     (See  Figs.  11  to  14.) 

Brehmer  ('85)  was  one  of  the  first  in  modern  times  to  study  the 
functional  defects  in  connection  with  a  Itahitus  phthisiciis.  He  attached 
fundamental  importance  in  the  disposition  to  tuberculosis  to  a  congeni- 
tally  small  heart  with  disproportionately  large  lungs.  He  conducted 
his  sanatorium  treatment  Avith  the  idea  of  increasing  the  heart  power, 
and  by  his  success  considered  the  correctness  of  his  theory  demonstrated. 

Many  other  functional  and  structural  faults  have  been  brought  into 
relation  to  tuberculosis  in  the  same  way.  Among  these  may  be  men- 
tioned changes  in  the  numl)er  and  quality  of  elastic  fibers  (Hess,  '04; 
Tendeloo,  '01-02),  deficiency  of  the  thyroid  gland  (Lorand,  '05),  de- 
generation of  the  pneumogastric  nerve  (Mays,  "00),  and  cerebral  defects 
as  found  in  imbeciles  and  markedly  neurotic  persons,  ^lost  of  the  in- 
born anomalies  fall  short  as  sufficient  causes  of  predisposition  when 
taken  separately,  and  some,  indeed,  are  probal)ly  acquired  as  the  result 
of  tuberculosis  quite  as  often  as  they  are  inherited  causative  factors. 
This  is  true  of  snuill  hearts,  imperfect  thoraces,  and  nutritional  faults 
described  by  Landouzy    ('99)   and  Mosny    {'02,  '03)    as  "  paratubercu- 


86  RESISTANCE,  PREDISPOSITION,   AND   IMMUNITY 

loses."  It  is,  at  least,  hard  to  differentiate  those  which  are  due  to 
inherited  defects  from  those  dependent  on  early  and  mild  tuberculous 
infection;  or,  still  further,  those  resulting  from  other  diseases  in  the 
parents.  Besides  tuberculosis,  syphilis  and  alcoholism  in  the  parents 
are  well  known  as  potent  causes  of  physical  degeneracy  in  the  children 
which  render  them  subnormal  in  their  resistance  to  disease  in  general. 

Local  Predisposition. — Certain  tissues  and  situations  in  the  body 
seem  to  be  especially'  prone  to  tuberculosis,  and  while  mostly  explained 
by  mechanical  conditions,  which  favor  the  lodgment  of  the  bacillus, 
there  are  suggestions  of  a  greater  adaptability  for  infection  of  the  lungs, 
for  example,  as  compared  with  the  liver  or  muscles  due  to  biologic  dif- 
ferences in  the  cells.  The  predilection  of  the  lung  apices  is  explained 
in  several  ways :  ( 1 )  by  the  slower  air  current  favoring  the  deposit  of 
bacillus  dust;  (2)  by  the  irregularities  and  sharper  angles  of  the  bronchi 
in  this  situation  tending  to  retain  the  secretions  (Birch-Hirschfeld, 
'99)  ;  (3)  a  slower  blood  and  lymph  stream  mechanically  favorable  to 
hematogenous  infection,  and  because  of  the  defective  nutrition  thus 
produced.  Schmorl  ('01)  has  located  a  fibrous  groove  in  the  pleura 
opposite  the  posterior  segment  of  the  first  rib  which  is  often  associated 
with  the  anomalies  of  Freund  and  Hart  previously  mentioned,  and  which 
he  regards  as  a  local  predisposition. 

These  anatomic  theories,  taken  singly,  are  less  tenable  than  the 
physiologic  ones  so  ably  presented  by  Tendeloo  ('07)  and  which  attrib- 
ute the  differences  in  vulnerability  of  the  lung  apices,  as  compared 
with  other  portions,  chiefly  to  poorer  nutritional  conditions  dependent 
on  a  slower  blood  and  lymph  flow,  to  restricted  expansion  and  conse- 
quent slight  atmospheric  pressure  changes,  and  to  absence  of  venous 
stasis  in  the  apices,  the  latter  being  unfavorable  to  tuberculous  infection 
(see  also  Immunity). 

Another  explanation  of  apical  lung  disease  which  should  be  remem- 
bered is  that  an  extension  of  lymphatic  infection  in  the  neck  by  way 
of  the  pleura  is  possible.  Aufrecht  ('05)  has  long  held  that  infection 
of  the  lungs  in  particular  is  accounted  for  by  infarcts  caused  by  bacilli 
lodging  in  the  small  arterial  endings.  Von  Behring  ('06)  inclines  to 
the  same  view  of  primary  lung  infection,  no  other  reason  than  the 
physiologic  conditions  of  the  blood  circulation,  which  makes  the  lung 
act  as  a  filter,  being  needed  to  account  for  a  predilection  for  this  organ. 
The  same  reasoning  accounts  for  the  development  of  foci  in  the  kid- 
neys and  joints.  On  the  whole,  no  satisfactory  biochemic  theory  can 
be  adduced  which  accounts  for  local  predisposition,  although  there  are 
such  explanations  for  the  relative  immunity  of  some  tissues,  such,  for 
example,  as  the  stomach,  where  the  presence  of  hydrochloric  acid  is 
inimical  to  bacteria.      The  endothelia  of  the  alveolar  capillaries  and 


RESISTANCE  87 

serous  membranes  are,  however,  believed  to  have  a  special  affinity  for  the 
bacillus  poison  by  von  Behring  ('06)  (see  page  95).  An  apparent 
hereditary  locus  minoris  resisteniice  has  been  observed  by  Turban  ('00) 
in  that  the  lung  on  the  same  side  of  the  body  as  in  the  parent  was  first 
involved  in  the  children  of  19  out  of  22  tuberculous  families.  This  ob- 
servation was  confirmed  in  78  per  cent  of  28  families  among  the  author's 
('02)  cases.  In  one  family  where  the  father  and  four  children  were  con- 
sumptive, the  left  lung  appeared  to  be  attacked  first  in  all  of  them. 

Acquired  Predisposition. — In  the  absence  of  congenital  defects  or 
inborn  weakness,  there  is  no  doubt  that  numerous  causes  are  able  to 
produce  a  temporary  or  permanent  subnormal  resistance  to  tuberculosis. 
These  causes  are  frequently  of  greater  importance  than  heredity  and 
structural  weakness  because  tuberculosis  is  no  respecter  of  athletic  con- 
stitutions temporarily  made  susceptible,  and  is  oftener  unconsidered 
in  such  persons,  whereas  greater  care  is  bestowed  on  the  weakling. 

SPECIFIC    SUSCEPTIBILITY    FROM    PREVIOUS   TUBERCULOUS    IXFECTIOX 

Lymphatic  (Scrofulosis). — The  question  of  primary  and  secondary 
tuberculous  infections  has  become  of  increasing  interest  and  importance 
during  recent  j'ears,  and  largely  through  the  observations  of  von  Behring 
('03)  who  attaches  much  importance  to  the  ease  of  infantile  infection 
and  its  remote  consequences.  It  cannot  be  gainsaid  that  many  young 
adults  having  pulmonary  tuberculosis  appear  to  have  acquired  their 
first  infection  in  childhood,  and  subsequent  infections  led  to  the  ulti- 
mate outbreak,  or,  as  von  Behring  holds  to  be  more  probable,  resulted 
from  the  latent  bacilli  which  first  found  lodgment  in  the  tissues. 

It  is  highly  important  to  contemplate  the  three  possibilities  by  which 
von  Behring  explains  the  result  of  the  inhalation  or  ingestion  of  tuber- 
cle bacilli  in  early  life  and  their  primary  reception  into  the  tissues.  In 
the  first  place,  they  may  be  of  sufficient  number  or  virulence  to  produce 
immediate  and  fatal  infection.  Second,  they  may  be  able,  because  of 
less  nimiber  or  virulence,  to  produce  only  local  disease  in  the  lymph 
nodes  or  lungs,  which  accounts  for  scrofulosis  and  all  its  manifestations. 
According  as  the  disease  is  more  or  less  marked,  it  ma}^  or  may  not 
finally  lead  to  lung  tuberculosis  aftei*  this  incubation  stage.  Third, 
the  virus  may  be  so  weak  that  no  infection  results,  but  a  degree  of 
increased  resistance  is  established,  after  a  period  of  susceptibility  last- 
ing several  months  has  passed  by.  In  this  place  we  have  only  to  do  with 
the  last  two  hypotheses,  and  more  especially  with  the  clinical  evidence 
of  a  specific  susceptibility  under  the  name  of  a  "  scrofulous  diathesis," 
as  it  is  vaguely  termed  in  tlie  older  medical  works. 

It  is  a  complex  matter  at  best  since  no  clear  distinctions  can  be  made 


88  RESISTANCE,   PREDISPOSITION,  AND   IMMUNITY 

between  morbid  processes  due  to  the  tubercle  bacillus  which  set  up 
chronic  lymphoid  hyperplasia  and  those  due  to  other  bacteria  alone  or 
associated  with  the  tubercle  bacillus.  Clinically  it  is  customary  to  dis- 
tinguish between  a  tuberculous  and  nontuberculous  scrofula  only  by  the 
test  of  time,  and  yet  all  forms  are  clearly  predisposing,  or  at  least  are 
frequently  followed  b}^  some  other  form  of  tuberculosis.  It  is  therefore 
proposed  by  many  writers  to  abolish  the  term  altogether  and  class  all 
cases  as  lymphatic  tuberculosis.  Nevertheless,  it  seems  to  the  writer 
justifiable  to  retain  it  for  nontuberculous  lymph-node  affections  pro- 
duced by  the  streptococcus  and  other  pyogenic  organisms,  which  are 
assumed  to  exist,  and  certainly  prepare  the  soil  for  the  tubercle  bacillus. 
For  the  practical  application  of  preventive  measures,  it  is  needful,  there- 
fore, to  consider  scrofulosis  as  a  strong  predisposing  factor. 

Pulmonary. — -An  important  practical  question  connected  with  former 
attacks  of  pulmonary  tuberculosis  concerns  the  danger  of  reinfection 
after  the  clinical  healing  of  the  disease,  or  in  subjects  with  so-called 
latent  pulmonary  tuberculosis.  Little  proof  has  been  produced  that  a 
special  disposition  to  external  infection  is  brought  about  by  the  first 
attack,  yet  it  must  be  acknowledged  that  secondary  autoinfection  is 
frequent  in  the  lungs,  larynx,  and  intestine,  as  well  as  in  other  organs 
of  individuals  with  open  disease.  It  shoiild  be  recalled,  however,  that 
under  these  circumstances  any  weak  moment,  whether  due  to  existing 
tuberculosis  or  not,  may  play  the  part  of  a  predisposition,  when  great 
numbers  of  bacilli  are  ever  present  and  ready  to  enter.  On  the  other 
hand,  the  tendency  to  localization  at  the  point  of  entrance  into  the 
mucosa  is  regarded  as  a  sign  of  resistance  by  von  Behring  (see  page 
93),  and  may  repel  a  secondary  infection  from  outside  sources  more 
vigorously  than  normal,  particularly  in  adult  life  under  natural  ex- 
posure. 

So  far,  then,  as  can  be  proved,  the  role  of  a  specifically  acquired 
susceptibility  in  favoring  a  fresh  infection  from  without  is  at  most  very 
slight  and  not  supported  by  animal  experiments,  while  the  reverse  effect 
— i.e.,  an  acquired  protection,  has  an  experimental  basis  (see  Immu- 
nity). On  its  face  this  statement  appears  wdiolly  contradicted  by  the 
clinical  observation  of  successive  attacks  of  pulmonary  tuberculosis  in 
subjects  previously  healed  in  the  clinical  sense.  Yet  it  must  be  remem- 
bered that  most  of  these  relapses  can  be  traced  to  autoinfection  from 
an  old  focus  and  not  to  new  bacilli  from  outside.  Moi'eover,  the  idea 
of  multiple  cumulative  infections  in  children  exposed  to  family  tuber- 
culosis is  not  necessarily  incompatible  with  a  relativel}^  increasing  though 
insufficient  resistance  to  external  infection. 

The  exact  truth  about  specific  susceptibility  may  require  years  of 
further  observation  to  settle. 


RESISTANCE  89 

NONSPECIFIC    SUSCEPTIBILITY 

Infectious  Diseases. — The  other  infections  preceding  or  following 
the  reception  of  tubercle  bacilli  into  the  body  are  probably  the  most 
important  factors  in  predisposition.  In  childhood  the  familiar  picture 
of  meningeal  and  lymphatic  tuberculosis  following  the  exanthematous 
diseases  needs  no  comment.  Measles  and  whooping  cough  most  fre- 
quently lead  to  acute  outbreaks  of  tuberculosis;  tonsillitis,  diphtheria, 
and  influenza  to  the  scrofulous  t}^es  of  the  disease  in  the  young.  The 
role  of  these  infections  in  adults,  if  not  also  in  older  children,  is  doubt- 
less more  often  that  of  spreading  a  preexisting  latent  tuberculosis. 

Influenza  comes  first  in  this  class,  comprising  an  antecedent  history 
in  15.5  per  cent  of  Ifi^Q  of  the  writer's  cases  where  an  exciting  cause 
was  referred  to,  while  colds  were  recorded  in  22.2  per  cent  as  forerunners 
of  the  onset  of  tuberculosis. 

Pneumonia  and  pneumococcus  infections  in  general  are  associated 
with  the  etiology  of  pulmonary  tuberculosis,  but  to  what  extent  is  not 
known.  The  principal  difficulty  arises  in  deciding  Avhether  lobar  pneu- 
monia precedes  or  accompanies  the  pneumonic  form  of  tuberculosis, 
or  whether  the  latter  is  quite  independent  of  it.  A  history  was  obtained 
in  nearly  six  per  cent  of  the  cases  collected  by  Jacob  and  Pannwitz 
('01-'02),  and  in  six  and  a  half  per  cent  of  the  writer's.  In  many 
cases  the  diagnosis  is  too  indefinite  to  make  the  estimates  accurate. 

Pleuritis. — A  history  of  a  former  pleurisy  as  an  independent  affec- 
tion, either  dry  or  exudative,  was  given  by  eleven  per  cent  of  the 
writer's  patients.  Such  a  large  proportion  of  pleurisies  have  been  found 
tuberculous  in  recent  years,  if  one  may  judge  by  the  results  of  the 
tuberculin  test,  that  but  little  value  can  be  given  to  such  figures  as  an 
evidence  of  predisposition.  Streptococcus  and  pneumococcus  pleurisies, 
nevertheless,  are  probably  locally  predisposing.  The  subacute  and  chronic 
catarrhal  respiratory  affections,  such  as  tracheobronchitis,  when  not 
symptomatic  of  tuberculosis  are  difficult  to  bring  into  a  causative  rela- 
tion to  it. 

Bronchitis  was  a  histor}^  in  three  per  cent  of  the  writer's  cases,  most 
of  which  were  doubtless  symptomatic.  In  the  upper  air  passages  the 
nasal  obstructions,  adenoid  hypertrophies,  and  atrophic  changes  of  the 
mucosa  which  are  the  sequelae  of  various  acute  infections  probably  play 
a  more  important  part  than  the  catarrhal  processes  per  se. 

Typhoid  fever  is  so  often  confused  with  tuberculosis  that  its  relation 
to  it  is  hard  to  establish.  In  4.2  per  cent  of  the  writer's  cases  a  history 
of  alleged  typhoid  was  associated  with  the  tuberculosis.  It  could  hardly 
fail  to  be  an  occasional  factor,  especially  in  infection  by  way  of  the 
intestine. 


90  RESISTANCE,   PREDISPOSITION,  AND   IMMUNITY 

Acute  gastro-intcstinal  catarrh  is  in  the  same  category  with  typhoid 
as  a  means  of  producing  conditions  favorable  to  intestinal  infection, 
particularly  in  infants. 

Malaria  was  mentioned  as  a  causative  factor  by  2.09  per  cent  of  the 
writer's  patients.  Such  histories  depend  chiefly  on  the  presence  of 
malaria  in  the  region  in  which  these  patients  reside.  The  symptoms 
of  tuberculosis  are,  no  doubt,  very  often  mistakenly  attributed  to  ma- 
laria because  of  their  similarity.  Hence  but  a  small  role  can  be  given 
to  it  in  predisposition  when  measured  by  such  standards. 

Rheumatic  fever  is  rarely  followed  by  tuberculosis,  and  the  heart 
complications  resulting  in  passive  congestion  are  thought  to  act  antago- 
nistically to  it  (see  page  92). 

Of  the  venereal  infections,  gonorrhea  and  syphilis,  both  are  fre- 
quently associated  with  tuberculosis,  but  whether  as  especially  aiding 
its  development  may  be  doubted.  In  fact,  the  erroneous  idea  that 
syphilis  is  protective  has  been  held  (Portucalis,  '99).  Syphilis  was 
present  in  1.3  per  cent  of  the  writer's  private  cases,  but  in  a  large  series 
of  hospital  cases  from  3  to  6  per  cent  are  recorded  (Sargent,  '07; 
Mauthe,  'OO-'Ol).  Association  with  depraved  habits  which  are  equally 
harmful  to  health,  and  the  large  percentage  of  venereal  diseases  in  the 
nontuberculous,  renders  a  decision  as  to  its  importance  impossible. 
Gonorrhea  is  said  to  favor  localization  of  the  bacilli  in  the  kidneys, 
bladder,  and  testes;  otherwise  it  acts  only  as  a  debilitating  factor  in 
general. 

Diseases  of  Nutrition. — Diabetes  MelUtns. — One  of  the  most  serious 
predispositions  from  diseased  conditions  is  conferred  by  diabetes.  Over 
one  quarter  of  its  victims  among  young  persons  die  of  tuberculosis. 
A  chemical  basis  is  assumed  for  this  susceptibility  in  that  sugar  favors 
the  growth  of  tubercle  bacilli,  but  other  elements  may  be  associated. 
Rachitis  is  probably  the  most  important,  next  to  diabetes,  in  favoring 
infection,  because  of  the  combination  of  thoracic  deformities  and  defect- 
ive development  in  general.  Turban  ('99)  found  10.8  per  cent  of  his 
cases  of  this  type;  the  writer  found  only  3  per  cent,  but  in  the  latter 
were  included  only  those  cases  with  marked  deformity  dating  from 
childhood. 

Gastric  and  intestinal  dyspepsias  and  chlorosis  are  too  often  symp- 
tomatic of  tuberculosis  and  other  diseases  to  be  classed  as  predisposing 
in  themselves,  though  this  cannot  be  denied  of  them. 

Nervous  Diseases. — Epileptic  families  are  very  frequently  tubercu- 
lous, while  neurotic  persons  in  general  easily  fall  victims  to  tuberculosis, 
No  direct  connection  can  be  assumed,  but  malnutrition  accompanies 
nearly  all  of  these  affections,  and  is  sufficient  to  account  for  their 
association. 


RESISTANCE  91 

Insanity. — Tuberculosis  carries  off  from  thirty  to  forty  per  cent  of 
melancholies  and  maniacal  insane  persons.  The  fasting  and  confine- 
ment, combined  with  opportunities  for  infection  and  traumatism,  have 
much  importance  here. 

Miscellaneous. — XcpJiritis  is  occasionally  antecedent  to  tuberculosis, 
but  of  doubtful  connection  with  it  in  a  causative  way.  Cancer  is  also 
occasionally  mentioned  as  one  cause  acting  by  its  debilitating  effect. 
Eczema  and  other  skin  diseases  may  be  included  with  predisposing 
factors  by  leading  to  inoculation  from  scratches,  etc. 

Injuries  (Traumata) . — Blows  on  the  chest  or  concussions,  as  in  rail- 
way accidents,  athletic  contests,  or  violent  strains,  are  capable  of  bring- 
ing to  light  a  latent  tuberculosis.  Contusions  and  the  consequent  ex- 
travasations of  blood  make  a  good  soil  for  tubercle  bacilli  which  may 
be  lurking  there  at  the  time  and  gain  access  to  the  part  through  the 
blood.  Thus  joint  and  meningeal  tuberculoses  are  rightfully  associated 
with  blows  or  falls.  Severe  nervous  shocks  and  overstrain  may  here  be 
included.  The  occurrence  of  tuberculosis  among  American  college  ath- 
letes is  also  significant  in  this  connection. 

Surgical  operations  may  give  the  impetus  to  a  slumbering  disease 
which  is  thus  wakened  to  activity.  This  is  occasionally  seen  after  oper- 
ations on  tuberculous  lymph  nodes,  for  appendicitis  and  other  abdominal 
diseases.  In  thirteen  of  the  writer's  cases  appendicitis  with  operation 
seemed  to  be  connected  with  a  subsequent  tuberculosis.  Aspiration  of 
a  pleural  exudate  and  section  of  a  fistula  in  ano  have  sometimes  been 
followed  by  miliary  tuberculosis,  presumably  produced  by  the  oppor- 
tunity given  for  a  large  number  of  bacilli  to  get  into  the  lymph  cir- 
culation. 

INCREASED    RESISTANCE 

Physiologic. — By  appropriate  measures  persons  of  subnormal  vigor 
may  enhance  their  resistance  to  tuberculosis.  One  of  the  most  impor- 
tant is  to  increase  the  digestive  power  and  assimilation  of  food.  Proteid 
and  fatt}^  foods  are  especially  adapted  for  this  purpose,  and  are  the 
ones  usually  least  preferred  by  the  so-called  predisposed  individual. 
Suitable  muscular  and  mental  exercises  promote  resistance,  while  recre- 
ation in  the  open  air  and  athletic  sports  in  moderation  aid  greatly. 

Occupation. — Open-air  occupation  increases  the  resistance  of  the 
respiratory  tract  to  changes  of  temperature,  and  promotes  heart  power. 
Coal  miners  are  said  to  be  relatively  immune  because  the  dust  lodged 
in  the  lungs  creates  an  unfavorable  soil  for  tlie  bacillus — an  improbable 
explanation.  Likewise,  it  has  been  alleged  that  sulphurous-acid  fumes 
formed  in  wood-pulp  manufacture,  the  ammonia  from  stables,  and  the 
balsamic  emanations  in  the  forests  act  directly  as  a  protection  by  their 


92  RESISTANCE,   PREDISPOSITION,  AND   IMMUNITY 

antiseptic  qualities.  Such  theories  are  no  longer  worthy  of  attention, 
the  freedom  from  infection,  if  any,  being  attributable  to  absence  of 
other  conditions  necessary  to  bring  it  about. 

Diathetic. — A  familiar  observation  is  the  relative  immunity  to  tuber- 
culosis among  lithemic  individuals.  The  gouty  diathesis  also  appears 
to  promote  chronicity  in  the  disease,  when  present.  On  the  theory  that 
an  excess  of  the  products  of  nitrogen  metabolism  are  in  the  blood,  and 
make  an  unfavorable  soil  for  the  bacillus,  the  administration  of  urea 
was  advocated  by  Harper   ('01)   as  a  therapeutic  agent. 

Diseases. — Mitral  Heart  Disease. — The  supposed  antagonism  from 
mitral  heart  disease,  accompanied  by  venous  congestion  of  the  lung, 
rests  on  clinical  observations  of  arrested  pulmonary  tuberculosis  in 
individuals  who  have  this  complication.  Whether  an  actual  antagonism 
to  infection  from  this  cause  really  exists  is  questioned  by  G.  W.  jSTorris 
('04)  as  the  result  of  a  collective  study  of  pathologic  material.  The 
excellent  results  of  Bier,  who  introduced  the  treatment  of  localized 
tuberculosis  on  the  theory  of  venous  stasis,  nevertheless  incline  to  sup- 
port the  above  explanation. 

Emphysema  and  asthma  are  supposed  to  confer  some  protection  on 
individuals  who  suffer  from  these  maladies.  If  they  are  not  already 
symptoms  of  tuberculosis  of  a  chronic  t3'pe  they  may  act  by  venous 
congestion,  as  in  mitral  insufficiency,  to  which  some  cases  are  related 
anyhow. 

Specific  Increase  of  Resistance. — The  possibility  of  an  hereditary 
resistance  acquired  by  certain  races  has  already  been  referred  to  (page 
83).  If  its  existence  is  admitted,  it  is  less  discoverable  in  the  indi- 
vidual than  in  the  race  or  family  as  a  whole. ^  There  is  more  reason 
to  assume  a  gradually  acquired  resistance  after  birth,  which  amounts 
to  immunity  in  those  individuals  who  were  unquestionably  exposed  to 
the  infection  without  evidence  of  infection  having  ever  occurred.  To 
this  class  possibly  should  be  added  those  numerous  instances  of  slight 
localized  infections  which  leave  cicatrices  in  the  lungs  or  lymph  nodes. 
On  the  other  hand,  it  cannot  be  assumed  that  a  specific  resistance,  de- 
veloped for  a  time  by  exposure  to  a  harmless  infection,  necessarily  per- 
sists beyond  a  limited  period,  especially  when  only  fibrous  or  chalky 
remains  of  the  transient  infection  are  present.  Fortunately,  during 
good  health  adults  enjoy  a  large  degree  of  natural  or  acquired  resist- 
ance, judging  from  the  rare  development  of  the  disease  under  such 
conditions  of  exposure  as  serve  to  infect  weaklings  and  children. 

>  Reibmayr  ('94)  attributed  the  more  benign  course  of  tuberculosis  in  England 
and  Germany  to  a  decreasing  virulence  due  to  a  gradual  immunizing  process  in 
these  races. 


IMMUNITY  93 

In  the  families  of  sufferers  from  "  inlierited "  tuberculosis  in  the 
old  meaning  of  the  term,  there  is  found  some  support  for  the  idea  of 
a  partial  immunity,  inherited  or  acquired  from  parental  sources.  This 
is  observed  in  the  greater  chronicity  and  duration  of  the  disease  in  such 
families,  and  has  been  used  as  an  argument  both  for  the  inheritance 
of  the  disease  and  a  special  resistance  to  it.  The  acquisition  of  lym- 
phatic or  bone  tuberculosis  early  in  life,  which  is  mild  in  character,  as  a 
rule,  is  often  followed  by  a  very  mild  type  of  pulmonary  tuberculosis. 
It  is,  therefore,  not  necessary  to  attribute  the  increased  resistance  to 
an  inherited  influence,  as  early  infection  is  the  rule  in  family  tuber- 
culosis. The  late  Dr.  Edwin  Solly  ('95),  of  Colorado,  made  the  inter- 
esting observation  in  his  patients  that  more  lasting  "  cures  "  or  chronic 
forms  among  pulmonary  cases  occurred  among  those  with  a  history  of 
family  tuberculosis  than  those  without  it.  Turban  ('99)  noted  the 
same  thing,  while  H.  M.  King  ('01)  found  the  course  of  the  disease  a 
year  longer  in  103  carefully  recorded  fatal  cases  of  tuberculous  parent- 
age. Previous  acute  attaeks  of  tuberculosis  may  fairly  be  associated 
with  the  more  chronic  course  of  relapses,  especially  those  in  advanced 
age,  as  manifestations  of  specific  resistance. 

The  chronic  course  of  lupus  is  also  assumed  by  von  Behring  to  be 
a  sign  of  resistance  in  a  previously  infected  "  scrofulous  "  person  who 
acquires  an  added  infection  which  localizes  in  the  skin  because  of  the 
relatively  immune  lymphatic  system.  If  true,  it  is  an  illustration  that 
partial  immunity,  although  conserving  life,  is  not  always  desirable  for 
the  individual. 

IMMUNITY 

To  use  this  term  literally  in  connection  with  tuberculosis  is  unwar- 
ranted by  any  experiences  of  a  clinical  or  experimental  character  thus 
far  obtained.  The  possibilities  of  complete  immunity  under  all  condi- 
tions of  natural  exposure  and  experimental  inoculation  may  well  be 
doubted ;  but  the  suggestions  of  relative  auto-immunity,  mentioned  in 
the  preceding  paragraph,  combined  with  the  slowly  evolved  conviction 
from  experimental  research,  have  produced  a  belief  in  the  possibility 
of  a  high  degree  of  relative  immunity  against  tuberculosis.  This  fact 
gives  hope  for  its  future  application  in  the  prevention  of  tuberculous 
infection  in  the  human  race,  a  matter  of  transcendent  interest  and  im- 
portance. At  present  enough  is  demonstrated  of  the  value  of  immuni- 
zation in  bovines  to  make  certain  that  when  methods  are  perfected,  it 
should  not  only  apply  universally  to  animals  but  to  human  beings  as 
well. 

Experiments. — The  history  of  experimental  research  in  tuberculosis 
during  the  past  fifteen  years  has  much  to  do  with  attempts  to  protect 


94  RESISTANCE,   PREDISPOSITION,  AND   IMMUNITY 

animals  against  tlie  disease  by  vaccination  with  bacilli,  sterilized  or 
weakened  in  various  ways  b}^  tlie  use  of  extracts,  or  of  varieties  other 
than  those  capable  of  infecting  the  given  species  to  be  immunized.^ 
A  certain  degree  of  success  was  attained  at  the  beginning  of  these 
studies  by  Dixon  ('89),  Koch  ('90),  Klebs,  Grancher  ('90),  Hericourt 
('92),  and  Trudeau  ('93)  on  guinea  pigs  and  rabbits.  Later  de 
Schweinitz  (03)  and  Trudeau  ("03-"06)  found  a  very  high  resistance 
established  in  guinea  pigs  by  inoculations  of  bacilli  of  weak  virulence, 
while  still  later  MacFadyen,  von  Behring,  and  Pearson  ('02-'06),  and 
Gilliland  ('02)  simultaneously  found  that  cattle  could  be  protected  by 
inoculations  of  human  bacilli.  Koch,  Neufeld  ('04),  and  Schiitz  ('03) 
also  established  the  same  fact.  Methods  by  which  success  was  obtained 
in  diphtheria  and  tetanus  were  found  of  no  avail  by  the  majority  of 
investigators.  Maragliano  ('95,  '04,  '05)  has  been  the  chief  exponent 
of  antitoxic  methods,  and  more  recently  Marmorek  ('03-'04)  has  claimed 
successful  results  by  means  of  sera,  but  the  proof  has  not  been  con- 
vincing. Preparations  of  dead  bacilli  confer  some  degree  of  immunity, 
but  the  greatest  success  has  been  obtained  by  living  bacilli  in  a  feebly 
virulent  condition.  All  soluble  extracts  have  failed  to  excite  a  specific 
immunity,  although  they  give  rise  to  certain  antibodies  in  the  serum 
of  injected  animals.  In  his  painstaking  researches  over  a  decade  ago 
Koch  ('97)  came  to  the  conclusion  that  the  washed  body  substance  of 
pulverized  bacilli  (T.  E.)  of  virulent  strains  was  the  best  immunizing 
agent.  Von  Behring  ('07),  in  his  latest  published  statements,  con- 
siders that  partly  extracted  "  Rest "  bacilli,  treated  with  chloral  hydrate 
and  other  salts,  produce  the  best  results.  The  problem  seems  in  a  fair 
way  to  1)0  solved  by  these  diligent  studies. 

Application. — Cattle. — The  immunization  of  young  calves  has  been 
carried  on  rather  extensively  in  Germany  and  Austria  by  the  "  bovo- 
vaccine "  method  of  von  Behring,  which  consists  of  one  or  two  intra- 
venous inoculations  of  human  bacilli  cultures.  These  have  been  passed 
through  guinea  pigs  before  cultivation  for  the  preparation  of  vaccine, 
and  are  dried  before  use.  The  bacilli  are  not  sterilized,  but  weakened 
by  desiccation.  Pearson  has  been  the  pioneer  in  this  field  in  America, 
and  has  applied  intravenous  human  bacilli  inoculations  in  Pennsyl- 
vania to  a  large  number  of  cattle,  and  demonstrated  the  value  of  the 
method  by  exposing  immunized  calves  to  natural  infection  together  with 
unprotected  animals,  and  with  complete  success  in  preventing  infection 
in  the  protected  animals.  The  tuberculin  test  and  post-mortem  exami- 
nations established  this  beyond  a  doubt.    Valuable  confirmation  has  also 

"  A  review  of  these  experiments  is  presented  by  Pearson  in  the  Second  Annual 
Report  of  the  Phipps  Institute. 


IMMUNITY  95 

been  fiirnislied  l^y  Calmette  and  Guerin  ('06)  and  Yallee  ('06)  in 
Prance,  who  carried  on  similar  tests,  and  furthermore  found  that  calves 
could  be  protected  by  feeding  the  protective  virus  in  milk. 

The  chief  drawback  in  the  immunization  of  cattle  at  present  is  in 
the  use  of  living  bacilli  which,  though  harmless  for  cattle,  may  remain 
latent  in  the  tissues  and  be  a  source  of  danger  in  the  flesh  and  milk. 
If  the  later  preparations  used  by  von  Behring,  "  tuberculase ''  and 
"  tulase,"  which  are  claimed  to  have  all  the  properties  of  living  bacilli 
except  the  power  to  grow,  shall  prove  to  be  equally  as  good  as  the 
living  virus,  a  great  advantage  will  be  gained.  The  application  of 
specific  immunization  to  man  will  then  logically  follow.  It  would  be 
unsafe  to  predict  the  limitations  of  its  use  at  present,  or  the  duration 
of  the  protection.  jSTo  facts  are  available  as  yet  to  answer  these  ques- 
tions, but  even  if  the  protection  is  but  a  matter  of  months,  the  period 
of  greatest  danger,  according  to  present  views  of  primary  infection 
(that  of  childhood),  might  be  tided  over  when  by  the  growth  of  natural 
resistance  virtual  immunity  is  assured. 

Explanation  of  Mechanism. — The  study  of  immunity  problems  in 
general  has  brought  aid  in  the  understanding  of  the  reaction  of  the 
animal  tissues  to  a  tuberculous  infection.  The  tubercle,  as  a  unit,  has 
also  much  in  its  structure,  reactions,  and  transformations  that  interprets 
the  resisting  mechanism  of  the  body  cells.  Stress  must  be  laid  at  pres- 
ent on  the  leucocytes  and  lymphoid  tissue  as  being  subject  to  changes 
during  the  immunization  process,  by  which  a  more  vigorous  defense  is 
presented  to  invading  bacilli.  The  condition  of  tuberculin  suscepti- 
bility is  apparently  a  necessary  phase  of  immunity,  and  may  exist, 
according  to  von  Behring,  without  the  presence  of  tubercles,  owing  to 
functional  alterations  in  the  lymphatic  tissues  and  endothelia  of  arteries 
and  serous  membranes.  However  this  may  be,  the  eye  inoculations  in 
the  immunized  rabbits  in  Trudeau's  ('93)  experiments  resulted  in  a 
massive  leucocytosis  and  more  marked  congestion  than  in  control  eyes, 
and  with  eventual  healing. 

The  evident  destruction  of  the  bacilli  by  the  leucocytes,  or  at  least 
their  presence  in  greater  number,  points  to  a  lytic  function  in  the  cells 
since  the  serum  alone  fails  to  reveal  it.  It  is  presumable,  then,  that  so 
long  as  the  susceptibility  lasts  there  is  heightened  phagocytic  and  lytic 
power.  "Whether  at  the  same  time  tolerance  is  developed  for  the  toxin 
set  free  in  the  blood  and  in  these  cells  surrounding  the  bacilli  or  the 
tubercles,  is  more  doubtful.  Only  when  no  local  caseation,  general  dis- 
turbance, or  cachexia  follows  the  death  of  the  inoculated  bacilli — i.  e., 
a  toxin  immunity — can  a  satisfactory  degree  of  protection  be  consid- 
ered established.  The  assimilation  and  transformation  of  the  endo- 
toxin by  certain  chemical  groups  in  the  body  cells  which  have  an  affinity 


96  RESISTANCE,   PREDISPOSITION,  AND   IMMUNITY 

for  allied  groups  in  the  bacilli,  is,  in  essence,  the  explanation  for  the 
immunity  phenomena  given  recently  by  von  Behring,  who  has  made  a 
most  thorough  study  of  the  problem.  In  the  actually  diseased  indi- 
vidual but  little  impression  is  made  on  the  cells  outside  of  the  aggre- 
gation about  the  tubercles  until  the  malady  has  progressed  to  an 
advanced  stage.  Then  increasing  resistance  may  seem  to  be  developed 
gradually  and  lead  to  an  arrest  or  ehronicity  of  the  disease.  Such 
immunity  comes  too  late  to  be  efficacious  in  saving  life,  but  by  inilu- 
encing  the  cells  outside  the  tubercle  artificially  during  favorable  stages 
of  the  disease  one  has  the  best  rationale  for  the  use  of  immunizing 
tuberculins,  as  introduced  by  Koch  and  von  Behring. 

SPECIFIC    SUBSTANCES    IN    THE    BLOOD 

Agglutinins  and  Precipitins. — The  most  prominent  change  discov- 
erable in  tlie  blood  of  animals  injected  with  bacilli  or  extracts  of  the 
same  is  the  development  of  agglutinating  or  precipitating  power  for 
them.  Its  significance  appears  to  be  no  greater  than  in  other  diseases, 
and  it  does  not  seem  necessary  to  immunity.  On  the  contrary,  quite 
strong  agglutination  power  may  be  present  without  immunity.  It  is 
probable  that  this  function  tends  to  localize  the  infection  and  that  the 
precipitins  are  practically  identical  in  effect. 

Opsonins  were  demonstrated  by  Wright  as  reaction  products  concerned 
in  immunity,  which  aid  in  the  process  of  phagocytosis.  The  specificity  of 
this  function  in  tuberculosis  has  been  demonstrated,  but  its  apparent 
independence  of  the  agglutinating  function  is  not  to  be  assumed  as 
yet.  The  opsonic  index,  as  a  measure  of  resistance,  is  of  uncertain 
value  in  actual  use  thus  far,  yet  in  the  hands  of  its  discoverer  tuber- 
culin treatment  is  claimed  to  be  more  successfully  administered  by  its 
guidance. 

Antitoxins  have  not  been  demonstrable  by  the  usual  methods  in 
vogue  with  diphtheria,  etc.,  except  in  the  hands  of  Maragliano  ('95), 
Marmorek  ('03),  and  a  few  others.  The  development  of  true  antitoxin 
for  tuberculosis  is  a  priori  unlikely,  inaspiuch  as  the  bacillus  resembles 
typhoid,  streptococcus,  staphylococcus  and  other  bacteria,  etc.,  in  which 
cell  endotoxins,  as  distinguished  from  secreted  toxins,  play  the  prin- 
cipal part  of  the  disease.  To  this  class  of  toxins  the  antitoxic  or  neu- 
tralizing properties  of  the  tissue  cells  are  not  free  in  the  serum,  so  far 
as  has  been  proved.  Antibodies  having  two  affinities  (amboceptors) 
have  been  demonstrated  in  the  serum  by  Widal  and  Le  Sourd  ('01), 
Camus  and  Pagniez  ('01),  and  the  writer  ('04).  These  are  not  true 
antitoxins  in  the  sense  of  diphtheria  and  tetanus,  but  are  apparently 
related  to  the  agglutinin  or  opsonin. 


IMMUNITY  97 

Antituberculin  was  assumed  by  Wasserman  and  Brack  ("06),  who 
examined  the  serum  and  tissues  of  tuberculous  subjects,  to  be  an  antibody 
set  free  from  the  tubercles  by  the  secreting  cells  surrounding  them.  By 
the  method  used  to  identify  it,  differentiation  from  the  agglutinins  was 
not  established. 

Lysins. — While  lytic  processes  exerted  on  tubercle  bacilli  can  be 
proved  to  take  place  in  the  tissues,  the  serum  does  not  reveal  such  powers 
as  does  typhoid  immune  serum.  In  the  disintegration  of  tubercle  bacilli, 
the  leucocytes  are  doubtless  most  important,  but  test-tube  experiments 
here  also  fail  to  give  information  of  value.  The  highly  resistant  wax 
composing  such  a  large  part  of  the  bacillus  is  readily  imagined  to  be 
difficult  to  dissolve  and  digest,  and  the  process  is  doubtless  slower  than 
with  most  other  bacteria  for  this  reason. 

SUMMARY 

The  biologic  processes  of  specific  immunity  against  tuberculosis  are 
at  least  twofold:  (a)  a  bacteriolytic  function,  involving  in  all  proba- 
bility agglutinating  and  opsonifying  action  by  the  serum;  (&)  a  toxin- 
binding  or  digesting  function  which  establishes  tolerance  after  a  period 
of  susceptibility,  provided  the  amount  is  correctly  adjusted  to  the 
capacity  of  the  individual's  cells  and  their  nutrition  is  well  maintained. 


98  RESISTANCE,   PREDISPOSITION,  AND  IMMUNITY 


ADDENDA 

Summary  of  Predisposition  and  Immunity,  Presented  at  the  Interna- 
tional Congress,  held  in  Washington,  D.  C. 

Of  the  contributions  presented  to  the  International  Congress  of 
Tuberculosis  at  Washington,  those  bearing  on  the  subject  of  predis- 
position and  immunity  should  here  be  noted. 

The  "  demineralization "  theory  of  predisposition  has  found  a  new 
supporter  in  this  country.  An  explanation  of  increased  calcium  excre- 
tion in  tuljerculosis  is  given  by  the  studies  of  Croftan  which  tends  to 
emphasize  the  importance  of  this  ekment  in  neutralizing  the  fever- 
producing  albumoses  set  free  by  the  disease. 

Several  valuable  contributions  have  been  made  to  the  subject  of 
inherited  predisposition.  To  be  mentioned  particularlj'^  is  the  work 
of  Prof.  Karl  Pearson,  who  has  made  a  more  careful  study  in  recent 
years  of  family  tuljerculosis,  and  comes  to  a  conclusion  decidedly  favor- 
ing the  theory  of  hereditary  predisposition. 

Szaboky  collected  statistics  from  1,456  tuberculous  and  1,433  non- 
tuberculous  individuals  from  which  he  determined  that  hereditary  pre- 
disposition was  of  equal  importance  to  acquired  disposition.  The  largest 
proportion  of  the  tuberculous  had  an  inherited  taint  which  was  one 
half  from  the  paternal  and  the  other  half  from  the  maternal  side.  In 
a  third  of  the  cases  the  disease  showed  itself  in  the  parents  before  the 
birth  of  the  children.  A  small  percentage  had  tuberculosis  in  grand- 
parents, and  the  least  in  brothers  and  sisters. 

Von  Unterberger  explains  a  transmitted  specific  vulnerability  by 
qualitative  differences  in  the  embryonic  chromosomes. 

Hart  has  continued  his  studies  of  structural  anomalies  of  the  upper 
thoracic  aperture,  and  maintains  his  views  as  to  their  importance  as  a 
predisposing  factor. 

This  predisposition  is  at  first  local  and  holds  for  any  manner  of 
infection,  whether  by  inhalation,  blood,  or  lymphatic  routes.  This 
leads  to  the  development  of  the  first  foci  in  the  apices.  Disarticulation 
of  the  first  rib  cartilage  has  been  seriously  proposed  as  an  aid  in  over- 
coming this  disposition   (Harrass,  '08). 

The  theories  of  Hart  as  illustrated  in  the  accompanying  photo- 
graphic reproductions   (Figs.  11  to  14  ^)  have  the  best  claim  to  recog- 

'  These  four  excellent  radiograms  have  been  kindly  supplied  by  Dr.  Carl  Hart 
and  are  reproduced  from  original  photographs  with  his  permission  and  through  the 
courtesy  of  his  publishers,  F.  Enke,  Stuttgart.  (See  Bibliography,  Hart,  '06  and 
Hart  and  Harrass,  '08.) 


J 

^ 

mS^f 

■■^ 

p 

I>>^J^^ 

M 

'  '  ^^^^ 

J 

IH^v': 

''l^^ 

Ni 

j^^^ 

^ 

Fig.  11.  —  Normal,  Well-Developed  Upper  Thoracic  Opening  ■mxH  Good 
Pronunciation  of  Paravertebral  Spaces.  Marked  age  ossification  of  costal 
cartilages. 


Fig.  12. — Typical  Stenosed  Upper  Thoracic  Opening  with  Asymmetry.  Pri- 
mary deformation  of  ribs.  Sheath  forming  ossification  of  cartilage.  Transition 
of  the  higher  human  form,  the  longitudinal  oval,  to  the  lower  mammalian 
form,  the  transverse  oval.  Absence  of  lateral  posterior  spaces.  Pressure  of 
ribs  has  caused  Schmorl's  furrow  in  lung  tissue. 

99 


Fig.  13. — Asymmetrical  Thoracic  Opening  with  Slight  Scoliosis  of  Cervical 
AND  Upper  Thoracic  Spine.  Abnormal  shortness  of  costal  cartilages  with 
sheath  forming  ossification. 


Fig.   14. — Formation   of  True  Joints  with  Epiphyses  and  Capsules.     Total 
senile  ossification  of  first  costal  cartilage.     Healed  tuberculous  foci  in  lung. 
100 


ADDENDA  101 

nition  in  explaining  apical  tuberculosis  where  anomalies  exist  in  the 
thoracic  structure. 

Under  the  name  of  "  asthenia  universalis,"  Stiller  describes  similar 
defects,  including  enteroptosis  and  floating  tenth  rib  due  to  congenital 
absence  of  the  tenth  costal  cartilage. 

A  contribution  to  the  fact  that  tuberculosis  is  a  potent  cause  of 
mental  degeneracy  is  to  be  found  in  the  statistics  of  6,000  cases  reviewed 
by  Barr,  from  England  and  America.  In  the  former  tuberculosis  was 
placed  second  and  in  the  latter  third  in  importance  as  etiological 
factors. 

The  familiar  effects  of  strain,  both  physical  and  mental,  in  bring- 
ing latent  tuberculosis  to  activity  are  certainly  logical  reasons  for  the 
belief  that  they  frequently  prepare  the  soil  for  infection.  No  better 
argument  for  an  eight-hour  working  day  is  needed  than  the  importance 
of  tuberculosis  preventive  measures. 

The  classic  experiments  of  Charrin  and  Eoger,  where  animals  which 
were  made  to  overwork  on  treadmills  showed  lessened  resistance  to  infec- 
tions, illustrate  the  principle  clearly. 

The  effects  of  worry  and  care  are  equally  potent  when  combined 
with  overwork  and  great  responsibilities. 

Special  dangers  are  associated  with  dusty  occupations,  such  as  stone- 
cutters and  metal  polishers.  Organic  dust  is  of  less  importance,  but  in 
statistics  can  be  shown  to  bear  some  relation. 

Hoffman  has  collected  an  interesting  table  of  thirty  dusty  occupa- 
tions showing  the  increased  incidence  of  tuberculosis  in  them. 

Experiments  with  the  purpose  of  inducing  artificially  immunity  in 
animals  have  been  continued,  but  the  prol)lem  is  not  yet  sufficiently 
solved  to  warrant  any  positive  assertions  about  the  value  of  these  methods. 

Eecently  certain  oleate  soaps  have  been  found  by  Koguchi  to  have 
restraining  or  bactericidal  properties  for  tubercle  bacilli  which  render 
them  useful  for  immunization,  while  the  studies  of  Bartel  on  the  modi- 
fying influence  of  lymphoid  tissue  on  their  virulence  which  serves  the 
same  purpose,  are  at  present  hopeful  fields  of  research. 

A  method  to  prevent  the  danger  by  inclosing  the  living  bacilli  in 
capsules  which  are  permeable  for  the  poisons,  is  employed  by  Heymans. 
The  capsules  are  introduced  subcutaneously  or  intraperitoneally,  and 
are  claimed  to  confer  a  high  degree  of  protection. 

Klimmer,  of  Dresden,  claims  equally  good  results  from  subcutaneous 
inoculation  of  living  cultures  of  human  type  wliich  are  modified  by 
passing  through  lizards,  so  as  to  lose  tlieir  virulence  for  mammals. 

Enough  experience  has  been  gained  at  present  to  show  that  the  pro- 
tection of  calves  is  of  limited  duration.  From  six  months  to  a  year 
after  vaccination  exposure  to  infection  is   well  resisted.     Afterwards 


102  RESISTANCE,   PREDISPOSITION,  AND   IMMUNITY 

bovine  tuberculosis  may  be  readily  inoculated  or  acqjuired  in  infected 
stalls. 

It  is  therefore  plain  that  repeated  vaccinations  would  be  required 
to  maintain  the  resistance,  at  least  until  the  maturity  of  the  animal 
fortified  by  previous  vaccinations  was  a  sufficient  safeguard. 

It  has  also  been  noted  that  for  two  months  after  the  immunizing 
inoculation  a  state  of  lowered  resistance  exists,  during  which  time  pro- 
tection from  infection  is  important.  Altogether  the  outlook  for  a  prac- 
ticable vaccination  against  tuberculosis  is  fair,  though  subject  to  some 
limitations. 

Many  new  theories  have  been  offered  as  explanation  of  the  mechan- 
ism of  immunity.  Of  interest  are  the  experiments  of  Opie,  pointing  to 
a  proteolytic  enzyme  activity  on  the  part  of  the  leucocytes  surrounding 
or  containing  the  bacilli. 

Of  interest  also  are  the  recent  experiments  by  Calmette,  which  have 
shown  that  the  serum  of  cattle  and  of  man  during  the  earlier  stages 
of  the  disease  will  act  as  complement  in  completing  the  hemolysis  of 
erythrocytes  saturated  with  cobra  venom.  This  property  is  said  to  be 
absent  from  the  normal  serum  and  in  the  acute  or  advanced  stages  of 
tuberculosis.  The  substance  is  thought  to  be  an  antibody  of  the  nature 
of  lecithin. 


PAKT   II 
FREQUENCY   AND   DISTRIBUTION 


CHAPTER   I 

FEEQUENCY    OF    TUBERCULOSIS 
By  ARNOLD  C.  KLEBS 

GENERAL    CONSIDERATIONS 

That  tuberculosis  is  a  very  frequent  disease  and  that  it  seems  dis- 
tributed over  the  civilized  world  is  now  a  more  generally  understood  fact, 
since  many  painstaking  investigations  have  supplied  the  data  for  infor- 
mation. Whether  such  investigations,  however,  can  ever  furnish  exact 
results,  as  almost  every  text-book  or  monograph  attempts  to  show,  must 
be  viewed  with  grave  doubt.  All  collective  information  on  frequency 
and  distribution  of  a  disease  is  naturally  based  upon  individual  infor- 
mation, and  in  chronic  diseases  it  is  almost  entirely  supplied  by  mortal- 
ity figures.  Individual  judgment  as  regards  diagnosis  is  subject  to  error, 
and  in  official  returns  is  often  influenced  by  outside  factors,  and  mor- 
tality statistics  cannot  give  exact  information  as  regards  the  importance 
and  disability-producing  qualities  of  a  given  disease,  since  it  counts  only 
the  dead  and  not  the  wounded.  These  general  considerations  do  not 
allow  us,  however,  to  set  aside  all  statistical  informations,  only  it  is 
essential,  in  order  to  get  a  clear  conception  of  actualities,  to  weigh  very 
carefully  the  source  of  information  before  basing  conclusions  thereupon. 

As  regards  the  frequency  of  tuberculosis  the  paradoxical  statement 
may  be  safely  made  that  tuberculous  infection  is  enormously  frequent, 
affecting  at  some  time  almost  ever3'body  in  a  civilized  community,  while 
the  disease  itself,  in  a  health-  and  life-threatening  degi'ee,  is  relatively 
much  rarer. 

FREQUENCY    IN    AUTOPSIES 

An  examination  of  all  bodies  would  undoubtedly  give  the  most  accu- 
rate information  as  to  the  frequency  of  tuberculosis  in  the  human  race. 
Lender  present  conditions,  however,  only  a  very  insignificant  number  of 
all  dead  comes  to  autopsy,  varying  in  different  countries  in  accordance 
to  a  greater  or  lesser  public  prejudice.  In  this  country  large  series  of 
postmortem  examinations  are  not  obtainable,  and  for  the  required  infor- 
mation one  has  therefore  to  turn  to  the  countries  of  the  European 
9  105 


106  FREQUENCY  OF  TUBERCULOSIS 

Continent,  where  autopsies  are  more  frequently  performed — as  a  rule, 
on  all  those  who  liave  died  in  hospitals.  The  hospital  population,  of 
course,  does  not  typically  represent  the  whole  ])opulation,  especially  not 
as  to  age  distribution  and  social  condition.  Its  largest  contingent  is 
furnished  by  the  working  classes.  For  this  reason  it  has  been  main- 
tained (Cornet,  '07)  that  it  is  entirely  erroneous  to  base  calculations 
about  the  frequency  of  tuberculosis  among  the  people  at  large  upon 
tuberculous  findings  in  autopsies.  But  since  tuberculosis  forms  par- 
ticularly a  problem  of  the  working  classes,  and  since  they  undoubtedly 
constitute  the  vast  majority,  information  derived  from  an  investigation 
among  those  classes  not  only  touches,  but  throws  the  strongest  light 
on  the  situation  as  it  is.  On  the  other  hand,  it  must  be  borne  in  mind 
that  only  the  sick  enter  the  hospitals,  and  of  these  only  those  dying 
form  the  basis  of  such  investigations;  also,  that  in  some  of  these  hos- 
pitals a  considerable  number  of  consumptives  find  admittance.  There  is 
therefore  a  good  reason  for  the  assertion  that  the  percentage  of  tuber- 
culosis found  among  such  a  material  is  not  applicable  to  the  population 
at  large. 

As  ])ointed  out  recently  by  Beitzke  ('09),  a  final  decision  about  the 
frequency  of  tuberculosis  is  at  present  impossible.  This  applies  with 
equal  force  to  the  calculations  by  which  the  frequency  is  most  usually 
determined,  based  upon  death  certificates  and  clinical  observation.  But 
while  a  final  decision  cannot  be  formed,  one  sufficiently  accurate  for 
the  practical  appreciation  of  the  magnitude  of  the  tuberculosis  problem 
can  be  deduced  from  observations  made.  The  principal  question  as  to 
what  is  to  be  considered  tuberculous  and  what  not  has  given  consider- 
able trouble  not  only  to  the  statistician  compiling  death  certificates,  but 
also  to  the  pathologist.  Eelatively  slight  divergencies  in  opinion  as  to 
what  lesions  are  to  he  regarded  as  tuberculous  often  are  responsible  for 
the  figures  obtained  by  different  observers.  It  is  also  true  that  the 
results  of  the  more  recent  serial  examinations  cannot  be  compared  with 
those  of  earlier  times,  because  of  late  a  more  diligent  search  has  been 
made  for  tuberculous  lesions.  And  it  is  well  demonstrated  that  it 
requires  special  training  to  discover  tuberculous  lesions.  The  discovery 
of  healed  and  apparently  insignificant  lesions  is  not  irrelevant,  as  has 
been  held,  because  only  through  a  painstaking  study  of  the  manifold 
reactions  caused  by  the  tubercle  bacillus  within  the  tissues  can  the  real 
significance  of  tlie  disease  be  determined. 

The  most  important  contribution  to  this  subject  was  made  by  Nageli 
('00).  He  investigated  500  bodies  with  particular  attention  to  tuber- 
culous lesions,  and  found  a  greater  frequency  of  tuberculosis  than  was 
previously  found  in  a  smaller  number  (100)  of  autopsies  performed 
by  Hanau  and  Schlenker  (G6  per  cent).     His  figures  have  been  widely 


FREQUENCY   IN   AUTOPSIES  107 

quoted,  and  substantiated  by  some  and  repealed  by  others.  The  differ- 
ence in  the  figures  obtained  by  later  observers  seems  to  be  due  less  to 
a  varying  frequency  of  tuberculosis  in  the  districts  where  the  exam- 
inations were  made  than  to  different  methods  of  investigation  and  also 
of  classification.  The  strongest  corroboration  of  Niigeli's  findings  was 
made  by  Burkhardt  ('06).  His  investigations  were  made  in  1,453 
autopsies  of  patients  who  died  of  various  diseases  in  Schmorl's  clinic  at 
the  Dresden  hospital.  He  used  the  same  methods  Niigeli  employed, 
except  that  he  did  not  include  as  tuberculous  "  slaty  "  indurations  and 
simple  adhesions  and  scars  of  the  apex  unless  there  was  distinct  reason 
for  doing  it.  Probably,  therefore,  his  figures  are  somewhat  lower  than 
Nageli's.  Outside  of  lethal  tuberculosis  he  distinguishes  (1)  latent- 
active  tuberculosis,  which  Avas  not  the  cause  of  death,  and  in  this 
definition  he  includes  all  fresh  caseations  in  the  lungs,  glands,  or 
elsewhere;  (2)  latent-inactive  tuberculosis,  as  the  former  being  found 
accidentally,  and  consisting  in  calcifications  (cicatrization  and  "slaty" 
induration  only  when  distinctly  tuberculous). 

Cornet  has  raised  an  objection  against  including  as  tuberculous  cal- 
cified foci,  because  they  contained  no  virulent  bacilli,  an  assertion  re- 
cently disproven  clearly  by  Lubarsch   ('08). 

The  findings  of  Burkhardt  are  best  illustrated  by  the  accompanying 
chart  (Fig.  15),  which  shows  the  distribution  of  tuberculous  findings 
in  the  various  age  groups.  It  is  seen  here  that  tuberculosis  proves 
most  dangerous  (53  per  cent)  in  the  most  active  years  of  life — i.e., 
between  eighteen  and  thirty — a  circumstance  noted  also  in  general  mor- 
tality statistics.  Another  acme  of  lethality  is  reached  between  the  ages 
of  five  and  fourteen.  This  latter  feature  is  absent  in  the  curve  obtained 
from  percentages  of  mortality,  probabl}^  because  of  a  different  nomen- 
clature used  at  those  ages  on  the  death  certificates.  The  curve  of  the 
eases  in  which  tuberculosis  was  the  cause  of  death  descends  gradually 
but  distinctly  from  the  thirtieth  year  on.  It  is  very  probable  that  this 
descent  would  not  be  as  marked  in  a  much  larger  material.  The  total 
number  of  cases  at  the  more  advanced  ages  is  too  small  to  give  reliable 
percentage  figures. 

Of  great  interest  is  the  curve  indicating  total  tuberculous  find- 
ings. Its  gradual  rise  up  to  96  per  cent  (Niigeli,  Burkhardt  93  per 
cent),  between  the  ages  of  twenty  and  ninety,  while  the  fatality  curve 
gradually  descends,  indicates  that  while  with  increasing  age  tubercu- 
lous infection  takes  place  more  frequently,  its  danger  decreases  for  the 
individual.  Translated  into  plain  language,  this  would  denote  that  all 
adults  harl)or  in  their  bodies  evidences  of  tuberculous  infections. 
Beitzke  ('09),  on  the  basis  of  his  findings  in  1,10()  autopsies  of  a 
similar  material  (Charite,  Berlin)  examined  by  the  same  methods  and 


108 


FREQUENCY   OF   TUBERCULOSIS 


with  a  similar  classification  as  the  one  used  hy  Nageli  and  Burkhardt, 
believes  that  only  about   50  per  cent  of  all  persons  become   infected. 


100 


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80 


70 


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40 


30 


20 


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AGE  PERIODS 
30  40  50 


60 


70 


90 


TOTAL  JUBl 

LRCULO 

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Fig.  15. — Distribution  of  Tuberculosis  at  the  Various  Age  Periods  (per 
100  cases  at  the  same  ages)  in  a  Series  of  1,400  Autopsies.  (After 
Burkhardt,  '06.) 

He  agrees,  however,  with  the  other  observers,  that  of  those  who  are 
examined  postmortem  at  metropolitan  hospitals,  this  is  the  case  in  prac- 
tically all  adults. 


AUTOPSIES    IN    CHILDREN 

Most  of  the  examinations  so  far  cited  include  only  comparatively 
small  numbers  of  children.  The  question  as  to  frequency  of  tuberculosis 
among  them  has  received  distinct  attention  in  the  last  years,  and  has 
brought  forward  most  significant  data.  Also  here  we  find  a  great  diver- 
gence of  figures,  not  exj^lainable  altogether,  as  has  been  done  again  and 


AUTOPSIES  IN   CHILDREN 


109 


again,  by  different  local  conditions.  A  slight  variation  of  method  will 
alone  alter  the  percentage  figures  very  considerably.  In  reviewing  them, 
this  mnst  always  be  borne  in  mind. 

The  followinsr  table  will  o^ive  a  good  survev  of  the  various  findings: 


Author 


Age  of  Children 


Miiller  ('89) 0  to  15  yrs. 


Number  of    i    Number  of 
Autopsies      Tuberculous 


('01). 


Councilman,  etc. 

Baginsky  ('02) 

Orth  ('04) 

Nageli  ('00) 

Burkhardt  ('06) 

Hamburger  and  Sluka  ('0.")). 

Hamburger-Ghon  ('07) 

Sehlbach  ('08) 

Beitzke  ('09) 


Otolo  ' 
Otolo  ' 
6  weeks 
to  15  ' 
0tol4  ' 
0tol4  ' 
0tol4  ' 
Otolo    ' 


500 
220 
806 
435 
88 

190 

401 

848 

1,423 

397 


209 
35 

144 
43 
15 

72 

160 

335 

180 

54 


Per  Cent 
Tuberculous 


42 
16 
18 
10 

17 

40 

40 
40 
13 
13.6 


The  variations  in  these  findings  are  quite  startling.  The  influence 
of  method  has  already  been  mentioned  as  one  cause  for  them.  Another 
one  must  be  found  in  the  greater  or  lesser  number  of  very  young 
children  (under  one  year  of  age)  which  help  to  make  up  the  total 
figures.     Thus  Beitzke,  for  instance,  finds  these  relations : 


Age 


Newly  born. . 

0  to  1  year . . 

1  to  5  years . 
6  to  15  years 


Number 


199 

109 

63 

26 


Tuberculous 


0 
11 
26 
17 


Percentage 


0 
10.1 

41.3 
65.4 


If  he,  therefore,  subtracts  from  his  material  all  children  under  one 
year  of  age,  his  figure  for  tuberculosis  frequency  would  be  48  per 
cent.  If  the  same  thing  is  done  in  some  of  the  other  statistics  we 
would  have :  Miiller,  44 ;  Hamburger  and  Sluka,  55 ;  and  Sehlbach,  40 
per  cent. 

A  special  search  for  tuberculous  lesions  in  early  childhood  in  larger 
series  of  autopsies  has  been  made  in  few  instances  only.  Quite  recently 
Martha  WoUstein  ('09)  has  analyzed  the  autopsy  material  of  the  New 
York  Babies'  Hospital.  This  hospital  admits  only  children  under  three 
years  of  age  (78  per  cent  under  one  year).  The  analysis  embraces 
1,131  autopsies.  In  185  (16.4  per  cent)  evidences  of  tuberculosis  were 
detected.  She  compares  her  results  with  those  of  Hamburger-Ghon 
('07)  during  the  first  year  of  life  in  the  four  (juarters,  as  follows 
(Hamburger,  318,  Wollstein,  88.3  autopsies)  : 


110 


FREQUENCY   OF  TUBERCULOSIS 


First 

Second 

Third 

Fourth 

4% 

18% 

23% 

Wollstein              

1.8% 

11% 

16% 

23% 

For  the  second  year:  Hamburger  (179  autopsies),  40  per  cent;  Woll- 
stein (192  autopsies),  34  per  cent,  first  half;  44  per  cent,  second  half. 

It  is  not  the  place  here  to  try  to  explain  the  reasons  for  the  very 
rapid  increase  of  tuberculous  findings  with  advancing  age.  It  is  inter- 
esting to  note,  however,  that  the  two  series  of  figures  from  Xew  York 
and  Vienna  pursue  a  remarkably  parallel  course. 

FREQUENCY    INTRA   VITAM 

Since  the  discovery  of  the  existence  of  hypersensibility  to  tuberculin 
in  tuberculous  individuals,  new  light  has  been  thrown  on  the  frequency 
of  tuberculosis.  Here,  also,  the  results  vary  according  to  method  used 
and  cases  selected.  But  in  general  it  can  be  maintained  that  the  tuber- 
culin findings  corroborate  those  obtained  at  autopsy.  Thus  Franz  found 
among  several  hundred  soldiers  of  the  Austrian  army  61  to  68  per 
cent  reacting  to  comparatively  small  doses  of  tuberculin  (1  to  3  mgm.), 
and  he  believes  that  with  the  higher  doses  he  would  have  reached  the 
96  per  cent  of  Nageli's  autopsy  series.  Yon  Pirquet  also  found  that 
practically  all  adults  react  to  the  cutaneous  tuberculin  test,  thereby,  as 
he  believes,  proving  that  almost  everybody  at  one  time  or  another  has 
been  infected  with  tuberculosis. 

Of  particular  interest  are  von  Pirquet's  ('09)  tuberculin  findings 
in  childhood.  They  are  best  illustrated  in  the  accompanying  graphic 
charts.  In  Figure  16  all  cases  (1,407)  are  shown,  with  the  exception 
of  those  suff'ering  from  measles,  in  which  the  cutaneous  test  is  always 
negative.  The  shading  denotes  all  reacting  cases.  From  5  per  cent 
in  the  first  year  the  percentage  of  reacting  cases  increases  rapidly,  until 
it  reaches. 80  per  cent  in  the  tenth  and  eleventh  years.  The  percentages 
of  those  cases,  however,  which  showed  evident  clinical  signs  of  tubercu- 
losis (marked  by  black  bars)  are  distinctly  below  those  with  positive 
tuberculin  reaction.  But  it  is  also  clear  that  the  earlier  the  age  the  more 
often  patients  reacting  to  the  test  also  have  signs  of  manifest  tuberculosis. 
Latent  tuberculosis,  therefore,  increases  with  succeeding  years. 

In  Figure  17  all  the  manifest  and  suspected  cases  of  tuberculosis 
(also  bronchitis,  anemia)  are  omitted,  leaving  1,134  children.  In  the 
first  two  years  there  is  no  shading,  indicating  that  at  that  age,  if 
tuberculous  infection  occurs  at  all,  it  produces  always  some  clinical 
symptoms  bronchitis  or  anemia.     Latent  tuberculosis  revealed  by  the 


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111 


112  FREQUENCY   OF   TUBERCULOSIS 

tuberculin  test,  on  the  other  hand,  reaches  in  similar  manner  as  before 
70  per  cent  in  the  tenth  year.'^ 

It  is  notable  how  closely  von  Pirquet's  results  correspond  with  the 
percentages  fovmd  by  Hamburger  and  others  in  autopsies.  The  subject 
will  of  course  need  further  investigation,  but  these  findings  of  early 
tuberculous  infections  are  extremely  suggestive,  especially  as  regards  the 
phthisiogenesis  in  later  life. 

It  will  be  remembered  that  von  Behring,  in  his  Kassel  address  ('03), 
laid  the  greatest  stress  on  the  occurrence  of  infection  in  early  childhood 
for  the  production  later  of  pulmonary  phthisis.  Andvord  ('08)  believes 
that  only  20  to  30  per  cent  of  the  lethal  cases  can  be  ascribed  to  acute 
infections  of  short  duration,  while  the  balance  was  acquired  primarily 
during  childhood.  The  time  between  tuberculous  infection  and  death 
is  therefore  of  very  variable  length. 

"TUBERCULOSIS    A    CHILDREN'S    DISEASE" 

The  view  that  tuberculosis  is  eminentl}^  a  children's  disease,  some- 
thing like  measles,  producing  fatal  results  at  once  in  early  childhood 
or  an  increased  resistance  against  evil  influences  in  later  years,  Avins 
more  and  more  adherents  during  the  last  years.  The  excellent  work  of 
Harbitz  ('05),  demonstrating  the  great  frequency  of  latent  glandular 
tuberculosis  in  childhood,  has  probably  first  drawn  more  general  atten- 
tion to  these  important  facts.  This  great  frequency  of  latent  tuber- 
culosis in  childhood  need  not  cause  grave  apprehensions,  as  expressed 
by  Schlossmann  ('08).  The  tuberculous  infection,  even  if  it  remains 
perfectly  latent,  produces  a  certain  degree  of  immunity  against  a  sec- 
ondary tuberculosis  (Hamburger,  '09).  Under  certain  not  yet  clearly 
defined  conditions  a  soil  can  be  prepared  for  pulmonary  phthisis.  These 
exceedingly  interesting  considerations  are  as  yet  largely  speculative. 
Their  full  meaning  is  discussed  elsewhere  in  this  work  in  greater  de- 
tail   (von  Pirquet,  Tuberculosis  in  Children). 

MORBIDITY    STATISTICS 

There  are  no  reliable  figures  which  can  give  anything  but  a  very 
approximate  idea  only  of  the  amount  of  sickness  produced  by  tuber- 
culosis in  a  given  population.  The  formula,  number  of  deaths  from 
tuberculosis  multiplied  by  three,  is  usually  employed  for  such  an  esti- 
mate.    The  result  is  entirely  meaningless,  and  exploited  mostly  to  im- 

^  In  this  chart  a  distinction  is  also  made  between  primary  and  secondary  re- 
actions, according  to  whether  the  children  reacted  to  the  first  test  or  the  second  test 
only.  Von  Pirquet  notes  it  as  a  common  occurrence  that  especially  older  children 
react  only  after  some  days  ("torpid  reaction")  or  only  to  a  second  test. 


MORTALITY  STATISTICS  AND  DECREASE  OF  TUBERCULOSIS      113 

press  the  public  witli  the  magnitude  of  the  proljlem.  Tlie  insidious 
onset  of  the  disease  and  its  eminent  chronicity  protect  it  from  discov- 
ery. It  often  disables  its  victim  for  months  and  even  years  before  its 
true  nature  is  recognized.  Even  a  rigidly  enforced  system  of  registration 
can  never  furnish  a  basis  for  accurate  estimation  of  the  damage  done 
by  the  disease.  The  nearest  approach  to  it  can  be  found  in  the  statis- 
tics of  standing  armies,  although  the  figures  must  necessarily  be  much 
smaller  than  in  total  population,  being  derived  from  a  corps  of  men 
scrutinized  carefully  as  regards  their  physical  fitness. 

For  1,000  of  active  troops  in  the  various  armies  of  the  Powers,  the  fol- 
lowing figures  for  cases  of  pulmonary  tuberculosis  are  obtained :  United 
States  ('06),  4.72;  Great  Britain  and  colonies  ('06),  2.4;  France  ('04), 
5.3;  Germany   ('03-'04),  1.5;  Austria   ('06),  1.0;  Russia   ('04),  2.7. 


MORTALITY    STATISTICS    AND    THE    DECREASE    OF 
TUBERCULOSIS 

If  mortality  statistics  are  analyzed  even  with  such  precautions  as 
have  been  alluded  to,  it  must  still  be  remembered  that  absolute  figures 
are  meaningless,  and  that  total  numbers  of  deaths  without  a  statement 
of  their  distribution  in  the  various  age  periods  conveys  no  valuable  and 
purposeful  idea  about  the  frequency  of  the  disease. 

The  age  distribution  of  tuberculosis  mortality  in  the  United  States 
is  shown  in  the  accompanying  table  and  Figure  18.    These  figures  of  the 


Consumption. 

1900. 

1890. 

Under  1  year 

1     "     

18.3 
9.4 
5 

3.6 

2  2 

10 '  6 

17.1 

70.6 

136.7 

153.7 

132 . 7 

113.6 

82.0 

67.0 

50.0 

39.5 

31.4 

25.8 

17.5 

11.2 

4.4 

1.6 

0.3 

0.1 

18.3 
10.3 

2  years                  

5 

3     "           

3.1 

4     "                   

2.4 

9.9 

10-14      "     

18.9 

15-19      "       

78:7 

20-24      "       

142.2 

25-29      "                    

149.0 

30-34      "                      

124 . 7 

35-39      "     

102.5 

40-44      "     

78.8 

45-49      "                   

65.4 

50-54      "                   

50.4 

55-59      "      

40.1 

60-64      "                 

34.7 

65-69      "                   

27.8 

70-74     ."                     

17.7 

75-79      '•                       

11.9 

80-84      "                   

5.2 

85-8!)      " 

2.0 

9()_94      "     

0.4 

95  and  up                          

0.2 

114 


FREQUENCY   OF  TUBERCULOSIS 


two  last  censases  show  the  tremendous  mortality  at  the  ages  between 
twenty  and  forty  years,  the  active  working  period.  Of  interest  is  the 
comparison  of  the  sets  of  figures  for  the  two  census  years  which  indicate 


rsso  ^tm 

1900   I  I 


H0M5kQk5|#3M-WTO-feM-70|-75|-80|-85l-90! 


£>ecreose 


/ncreose 


J/-af/onary 

Fig.  18. — The  Age  Distribution  of  Consumption  Mortality.  Proportions  of 
deaths  at  each  age  per  1,000  at  known  ages  from  consumption  1890  to  1900. 
(12th  U.  S.  Census  Reports,  vol.  iii,  1902,  p.  179.) 


an  increase  of  tuberculosis  during  the  age  periods  of  from  twenty-five 
to  fifty  years  of  age,  while  at  other  periods  it  has  either  decreased  or 
remained  stationary. 

If  one  compares  the  figures  of  death  from  tuberculosis  to  tlie  total 
population  at  given  ages,  as  has  been  done  in  Figure  19,  the  age  distri- 
bution of  tuberculosis' assumes  a  somewhat  different  aspect,  coi'respond- 


MORTALITY  STATISTICS  AND  DECREASE  OF  TUBERCULOSIS     115 


Pneumonia.  C 

Consumphion.  I 


-5  |-l0]H5|-20|-25l-30|-35|-40lwt5l-50l-55l-60^ 


Fig.  19. — Proportions  of  Deaths  from  Pneumonia  and  Consumption  at  Cer- 
tain Ages  to  1,000  Living  at  Those  Ages.  (12th  U.  S.  Census  Reports, 
vol.  i  and  iv.) 


116 


FREQUENCY   OF  TUBERCULOSIS 


Consumption. 

Pneumonia. 

Age. 

Total  number 
of  deaths. 

Per  1,000 
living. 

Total  number 
of  deaths. 

Per  1,000 
living. 

Under  1  year 

2,011 

1,168 

622 

375 

278 

4,454 

1,287 

2,210 

9,104 

16,031      - 

15,811 

12,805 

10,833 

8,376 

6,456 

5,465 

4,424 

3,652 

3,193 

2,396 

1,459 

615 

214 

49 

23 

0.47 
0.14 
0.27 
1.20 
2.10 
2.40 
2.30 
2.10 
1.90 
1.80 
1.80 
2.00 
2.03 
2.40 
2.70 
2.80 
2.40 
2.40 
2.04 
2.30 

19,662 
9,796 
4,.349 
2,189 
1,310 

37,206 
3,322 
2,042 
3,474 
4,326 
4,077 
4,065 
4,532 
4,431 
4,400 
4,700 
4,566 
5,198 
5,325 
5,156 
4,170 
2,725 
1,229 
336 
115 

1  "    

2  years       

3     "            

4     "                

5     "     

3.90 

5—9    years 

0.37 

10-14      ''    

0.25 

15-19      "            

0.45 

20-24      "     

0.58 

25-29      "     

0.62 

30-34      "          

0  73 

35-39      "          

0.91 

40-44      "    

1.04 

45-49      "     

1.20 

50-54      "    

1  50 

55-59      "     

2  06 

60-64      "                     .... 

2  90 

65-69      "     

4.08 

70-74      "     

5  80 

75-79      " 

8  02 

80-84      "     

1  08 

85-89      "     

1.30 

90-94      "     

1  40 

95  and  over 

1  17 

ing  to  the  lesser  number  of  people  living  at  the  more  advanced  age 
periods.  The  comparison  with  tlie  mortality  from  pneumonia  brings 
out  the  significant  fact  that  this  latter  disease  is  fatal  particularly  at 
the  two  extremes  of  life,  while  tuberculosis  overwhelmingly  affects  the 
Avhole  adult  life  periad.  By  virtue  of  this  fact  as  well  as  by  its  great 
disabling  power,  not  for  a  short  period  as  in  the  case  of  pneumonia  but 
for  long  months  and  years,  tuberculosis  constitutes  the  grave  social 
problem  which  is  now  engaging  the  whole  civilized  world  in  a  common 
effort  against  it. 


GEOGRAPHIC    DISTRIBUTION 

Here,  again,  our  knowledge  is  based  more  on  impression  than  on  a 
calculation  resting  on  accurate  figures.  It  would  lead  entirely  too  far  to 
enter  into  the  details  of  the  laborious  studies  of  the  subject  in  various 
districts  of  the  earth  made  by  Lombard,  Hirsch,  and  others.  The  chief 
fact  they  brought  out  is  the  even  distribution  of  tuberculosis  in  civil- 
ized lands  very  little  influenced  by  climatic  differences.  The  causes  for 
this  must  be  looked  for  in  certain  features  of  civilized  life  itself.  The 
attempt  made  to  assign  to  some  particular  defects  in  civilized  society 
the  chief  responsibility  for  the  prevalence  of  tuberculosis  must  be  re- 


GEOGRAPHIC  DISTRIBUTION  117 

garded  as  futile,  as  a  great  complexity  of  conditions  exists  in  different 
countries.  From  the  foregoing  it  has  been  seen  that  the  fact  of  infec- 
tion itself  (of  "exposition,"  as  termed  by  the  strict  contagionists)  plays 
probably  a  lesser  role  in  the  varying  production  of  tuberculosis  in  dif- 
ferent age  periods,  individuals,  and  races,  but  that  the  individual  resist- 
ance to  the  more  or  less  unavoidable  infection  is  the  determining  factor. 
The  last  shot  has  not  yet  been  tired  in  this  battle  of  opposing  theories. 


CHAPTER   II 

TUBERCULOSIS   AMONG   THE   DARK-SKINNED   RACES    OF 

AMERICA 

By  THOMAS   D.   COLEMAN 

Medical  history  teaches  that  there  are  exciting  and  predisposing 
factors  at  work  in  the  production  of  disease;  that  certain  races  are 
especially  subject  to  some  diseases,  while  they  are  markedly  resistant 
to  others.  Two  concrete  examples  are  sufficient.  The  negro  under  his 
present  environment  is  subject  to  tuberculosis  and  syphilis;  he  is  resist- 
ant to  malaria  and  yellow  fever.  The  Jew  is  susceptible  to  cancer  and 
diabetes;  he  is  resistant  to  tuberculosis  and  syphilis. 

Additional  evidence  is  furnished  by  the  animal  kingdom  of  suscep- 
tibility and  immunity.  According  to  Roger,  Algerian  sheep  are  refrac- 
tory to  anthrax  and  the  black  sheep  of  Bretagne  are  immune  to  murr. 
;, Animals  of  the  same  species  possess  varying  degrees  of  immunity, 
according  to  their  environment — e.  g.,  white  rats  fall  a  ready  prey  to 
anthrax,  while  gray  rats  are  to  a  large  extent  immune.  To  the  monkey 
in  his  jungle  life  tuberculosis  is  unknown ;  in  captivity  it  destroys  more 
of  the  species  than  all  other  diseases  combined.  Cattle  in  Japan  have 
been  singularly  free  from  tuberculosis;  in  this  country  and  Europe 
it  is  much  too  prevalent,  causing  enormous  financial  loss  and,  in 
the  light  of  our  present  knowledge,  is  a  prolific  source  of  infection 
in  man. 

Tuberculosis  was  almost  unlcnown  to  the  negro  in  his  savage  state, 
and  even  in  his  condition  of  slavery  in  this  country;  whereas  under  his 
changed  condition  of  freedom,  broadly  speaking,  it  carries  off  three  to 
four  of  this  race  to  one  of  the  Caucasian.  The  North  American  Indian 
furnishes  still  further  evidence  in  this  direction.  Before  the  invasion  of 
the  white  man  and  the  attendant  civilized  modes  of  life  to  which  he 
introduced  this  son  of  the  forest,  tuberculosis  was  unknown  among  the 
Indians;  now  it  is  a  frequent  invader  and  destroyer  of  his  race.  A 
similar  condition  of  affairs  is  noted  in  the  other  dark-skinned  races,  and 
even  the  light-skinned  races  which  are  newly  subjected  to  the  infection. 
These  are  matters  of  fact,  and  an  adequate  explanation  of  them  can  only 
be  found  by  appeal  to  the  theory  of  immunity.  Modern  pathology  is 
118 


TUBERCULOSIS  AMONG  THE  DARK-SKINNED   RACES         119 

based  on  the  theory  that  pathogenic  organisms  lose  their  virulence  in 
healthy  serum.  Immunity  is  probably  not  absolute  in  any  disease  except 
syphilis;  however,  it  is  relatively  so  in  such  diseases  as  variola,  varicella, 
scarlatina,  measles,  pertussis,  yellow  fever,  etc. 

Immunity  is  transient  or  evanescent  in  diphtheria,  pneumonia,  in- 
fluenza, malarial  fever,  etc.  Immunity  may  be  inherited  or  acquired; 
it  is  in  these  two  latter  phases  of  the  subject  that  we  find  a  working 
h3^pothesis  to  explain  why  tuberculosis  is  rare  or  infrequent  in  some 
races  and  yet  decimates  others.  In  the  Jewish  race  it  is  difficult  to 
explain  the  relative  infrequence  of  tuberculosis  except  on  two  theories: 
first,  an  immunit}'  acquired  throughout  an  eventful  history  of  more 
than  forty  centuries,  and  second,  tlirougli  the  careful  meat  inspection 
which  is  still  practiced  by  the  orthodox  Jews.  The  former  is  the  more 
logical  explanation. 

It  is  now  thought  by  many  that  a  relative  immunity  may  be  trans- 
mitted from  parent  to  child;  then  why  not  from  generation  to  genera- 
tion? On  this  theory  only  can  we  explain  why  whole  families  are  not 
destroyed,  instead  of  one  or  two  members,  by  tuberculosis,  when  it  occurs 
in  one  or  both  parents.  Additional  arguments  may  be  obtained  from 
other  infectious  diseases.  Small-pox,  when  introduced  among  a  new 
people  in  Iceland  in  1707,  caused  the  death  of  18,000  out  of  a  total 
population  of  50,000.  In  Mexico  and  other  newly  exposed  countries  a 
similar  sequence  of  events  happened.  Xow,  through  ages  of  infection 
and  vaccination,  it  is  a  milder  disease,  is  comparatively  rare,  and  a  read- 
ily controllable  infection;  so  much  so  that  its  spread  to  any  material 
extent  is  a  reflection  on  the  health  authorities  of  any  community. 

Syphilis  is  believed  by  some  to  have  been  introduced  into  the  Old 
World  from  the  Xew.  Whatever  may  be  the  merits  of  this  question 
from  an  historic  standpoint,  it  is  true  that  it  flrst  attracted  widespread 
attention  in  1191,  when  the  troops  of  Charles  VII  of  France  were 
fighting  in  the  expedition  against  Naples.  It  spreads  with  alarming 
rapidity  among  new  peoples. 

Measles  appeared  for  the  first  time  in  the  Faroe  Islands  in  181G. 
Of  7,782  inhabitants,  6,000  were  attacked. 

In  1875  in  the  Fiji  Islands,  40,000  out  of  a  population  of  150.000 
died  from  measles.  No  such  invasion  occurs  among  races  that  have 
been  exposed  to  this  disease  throughout  centuries,  or  even  years. 

Roger  states  that  predisposition  and  immunity  exists  in  varying 
degrees  in  peoples  of  the  same  race,  in  families,  and  that  there  are 
numerous  individual  variations.  These  are  usually  called  idiosyncrasies, 
a  good  example. being  those  individuals  in  whom  vaccination  fails.  In 
the  absence  of  a  better  explanation,  and  from  a  survey  of  clinical  ex- 
perience, both  past  and  present,  we  cannot  but  conclude  that  there  is  at 


120         TUBERCULOSIS  AMONG   THE   DARK-SKINNED  RACES 

present,  and  doubtless  always  will  be,  a  racial  immunity  and  suscep- 
tibility. 

By  this  we  do  not  mean  to  imply  that  the  immunity  or  susceptibility 
of  any  race  to  any  specific  disease  is  perpetual  or  will  continue  in- 
definitely; on  the  contrar}',  it  is  likely  that  these  conditions  will  undergo 
change  with  time  and  environment.  It  is  possible,  therefore,  that  suc- 
ceeding generations  of  these  dark-skinned  races  will  develop  a  constantly 
decreasing  predisposition  to  tuberculosis,  and  they  may  develop  a  degree 
of  immunity  to  it  that  is  now  enjoyed  only  by  the  Jew^^.  Until  such 
time  we  are  brought  face  to  face  with  the  problem  of  a  special  sus- 
ceptibility in  these  dark-skinned  races. 

Admitting,  then,  that  these  peoples  are  at  present  more  susceptible 
to  tuberculosis  than  are  the  whites,  it  is  interesting  to  inquire  into  the 
causes  which  account  for  this  particular  susceptibility.  The  writer  has 
chosen  to  call  this  susceptibility  racial,  not  because  these  peoples  have 
black  or  red  or  brown  or  yellow  skins,  and  therefore  their  opsonic  index 
is  low  or  high,  but  liecause  these  races  are  for  the  most  part  recently 
introduced  to  civilization  and  infection.  The  negro,  the  Indian,  and  the 
Eskimo  have  but  comparatively  recently  passed  from  an  uncivilized  to  a 
civilized  existence,  and  the  Eskimo  in  many  instances  still  holds  to  his 
semisavage  life,  living  in  thinly  populated  districts  and  arctic  regions. 
The  same  influences  which  have  kept  tuberculosis  from  being  a  scourge  to 
cattle  in  Japan  have  dou])tless  operated  to  make  the  disease  less  frequent 
among  the  Chinese  and  Japanese  at  home;  it  is  simply  a  matter  of 
exposure,  or  the  lack  of  it. 

The  civilization  of  these  people  antedates  that  of  many  of  the»white 
races,  but  they  are  not  protected  by  that  degree  of  immunity  which  has 
come  to  the  latter  through  centuries  of  exposure;  consequently,  when 
this  raw  material  comes  to  us  and  adopts  our  lower — not  higher — 
hygienic  modes  of  living,  tuberculosis  makes  rapid  and  fatal  inroads 
among  them.  This  point  finds  additional  proof  in  the  Irish.  The 
Emerald  Isle  is  venerated  by  the  Irish  as  is  Jerusalem  by  the  Jew 
and  Mecca  by  the  Mohammedan;  outside  of  Dublin,  Cork,  and  a  few 
other  large  cities  the  Irish  follow  largely  a  bucolic  existence.  When 
they  migrate  to  this  country  for  some  reason  they  settle  in  densely 
populated  cities,  and  make  a  radical  change  in  their  methods  of  exist- 
ence. Instead  of  becoming  farmers,  as  they  were  in  their  own  country, 
they  throng  the  cities,  becoming  politicians,  liquor  dealers,  clerks,  etc. 
Many  of  them  yield  to  the  temptations  and  dissipations  of  urban  life. 
Few  of  them  take  to  farming,  and  as  a  result  statistics  show  the  Irish 
to  be  more  vulnerable  to  tuberculosis  than  any  other  white  race.  Here 
again,  dissipation,  environment,  and  a  new  people  account  for  the 
prolific  harvest. 


TUBERCULOSIS   IN  THE   NEGRO  121 

TUBERCULOSIS   IN   THE   NEGRO 

After  having  studied  this  problem  for  nearly  two  decades  and  having 
known  the  habits  and  vices  of  the  negro  for  a  lifetime,  the  writer  has 
often  wondered  that  the  disease  is  not  more  prevalent  among  them. 
As  a  class  they  are  shiftless,  accepting  literally  the  biblical  injunction, 
"  Take  no  thought  of  the  morrow."  Necessity  with  them  is  not  the 
mother  of  invention,  but  the  one  and  only  incentive  to  work.  In  study- 
ing the  evolution  of  the  race  it  is  interesting  to  note  this  phase  of  its 
character.  In  their  condition  of  bondage  they  were  still  in  large  meas- 
ure Nature's  children,  living  for  the  most  part  in  the  open  and  tilling 
the  soil.  They  were  well  housed,  well  clothed,  well  fed,  and  when  sick 
were  attended  by  a  competent  physician,  for,  irrespective  of  any  motives 
of  humanity,  it  was  to  the  financial  interest  of  the  planter  to  have  his 
slaves  receive  as  good  medical  advice  as  could  be  obtained.  Except  for 
the  yoke  of  bondage  they  were  care-free  and  had  all  their  material  wants 
supplied. 

After  their  emancipation  they  required  for  their  maintenance  forty  to 
fifty  cents  per  working  day.  Heads  of  families  and  farm  hands  received 
before  emancipation  $8  to  $10  per  month,  and  their  rations  consisted  of 
one  peck  of  meal,  four  pounds  of  bacon,  and  a  quart  of  sirup  per  week. 
Usually  a  cabin  was  furnished  them,  and  around  this  they  cultivated  veg- 
etables such  as  they  needed,  consisting  mainly  of  cabbages,  collards,  etc. 
On  this  dietary  and  under  these  surroundings  they  waxed  strong  and  re- 
mained free  from  tuberculosis,  but  they  had  to  work  more  or  less  con- 
tinuously. Freedom,  the  march  of  civilization,  the  additional  demand 
for  labor,  and  politics,  have  made  them  forsake  the  plantation  for  the 
town.  Instead  of  being  care-free,  they  have  been  forced  to  care  for 
themselves;  instead  of  physical  work  for  which  they  are  at  this  time 
fitted,  their  brains  are  being  filled  w^ith  Latin  and  Greek  and  other 
accomplishments  of  a  higher  order,  for  w^hich  they  are  not  fitted;  re- 
straint is  withdrawn  from  them,  and  they  run  riot  in  dissipation  and 
vice;  they  reach  for  the  enjoyments  of  a  higher  civilization  without 
I)roper  preparation  or  equipment,  either  mental  or  moral. 

Instead  of  the  farm  hand  receiving  $8  to  $10  per  month  and  his 
keep,  he  receives  $10  to  $20;  instead  of  the  city  laborer  receiving 
seventy-five  cents  per  day,  he  receives  $1  to  $2.50  per  day.  The  result 
is  inevitable — the  farm  hands  drift  to  the  city,  where  they  live  under 
most  unhygienic  surroundings.  Instead  of  having  to  work  twenty-four 
or  twenty-six  days  per  month  to  obtain  a  livelihood,  this  can  be  gotten 
in  half  the  time  WMth  their  increased  wages,  and  the  rest  of  the  time  is 
given  over  to  idleness  and  dissipation.  Tlie  race  is  undergoing  an  evolu- 
tionary stage  at  present  which  for  the  most  part  leads  in  the  direction 


122         TUBERCULOSIS  AMONG  THE  DARK-SKINNED  RACES 

of  their  improvement,  but  those  philanthropists  who  think  to  benefit 
them  by  teaching  them  Latin  and  (Ireek  and  the  Komance  languages, 
are  working  a  double  injury  instead  of  a  blessing,  for  it  produces 
a  hybrid  which,  like  the  mule,  has  no  "  pride  of  ancestry  nor  hope 
of  posterity."  It  gives  the  negro  a  false  idea  of  his  position,  and 
henceforth  he  will  do  no  more  physical  work.  It  robs  the  country 
of  a  type  of  labor  that  might  be  beneficial  both  to  it  and  to  the 
laborer,  and  aside  from  this  emphasizes  the  difficulties  of  the  race 
problem. 

The  average  negro  is  ignorant  of  the  fundamental  laws  of  hygiene, 
and  the  following  picture  may  be  mviltiplied  throughout  the  South  not 
by  thousands  but  by  hundreds  of  thousands  of  times: 

A  negro,  once  a  hostler,  went  to  New  York  and  became  a  waiter.  He 
had  returned  home  to  die  of  tuberculosis.  He  and  his  family  lived  in 
two  rooms  and  a  kitchen;  the  front  room  was  used  as  a  parlor;  the  back 
room,  in  which  the  family  slept  and  which  was  perhaps  15  X  15  feet, 
was  lighted  by  one  window  and  a  door  which  looked  to  the  west  and 
caught  the  last  rays  of  the  setting  sun  when  they  were  left  open,  which, 
was  infrequent ;  the  other  opening  to  the  room  led  into  the  parlor.  The 
bed  clothing  was  doubtless  changed,  but  never  to  the  writer's  knowledge. 
A  common  towel  served  the  family,  as  did  also  a  tin  basin ;  flies  literally 
swarmed  in  the  room  and  were  crawling  over  the  patient's  face  and  the 
tomato  can,  which  was  used  as  a  cuspidor,  when  the  patient  was  inclined 
to  use  it  instead  of  the  floor.  The  air  in  the  apartment  was  heavy  and 
noisome.  A  brother  of  this  man,  who  slept  in  this  house,  was  a  coach- 
man. It  is  needless  to  state  that  several  of  this  generation  died  of  tuber- 
culosis.    The  others  have  been  lost  sight  of. 

This  presents  a  picture  which,  so  far  from  being  an  exaggeration, 
is  above  the  average  of  what  one  finds  in  studying  this  race.  Negroes 
are  given  over  to  dissipation;  sexual  excesses  and  venereal  diseases  exist 
among  them  to  an  extent  scarcely  to  be  comprehended  by  one  who  has 
not  lived  among  them.  It  is  claimed  that  from  fifty  to  seventy-five 
per  cent  of  the  negro  population  has  syphilis,  either  hereditary  or 
acquired.  While  statistics  ■  on  this  point  are  lacking,  this  opinion  is 
verified  by  every  Southern  practitioner.  Whisky  and  other  alcoholic 
drinks  prove  irresistible  temptations.  Nervous  diseases  and  insanity 
are  increasing  among  negroes  with  terrific  strides.  In  Georgia,  before 
the  Civil  War,  there  were  known  to  be  only  five  insane  negroes; 
now  the  State  lunatic  asylum  contains  more  than  a  thousand,  and 
hospitals,  jails,  and  poorhouses  and  many  homes  are  burdened  with 
them. 

There  are  two  other  ])hases  of  the  tuberculosis  problem  that  stand 
out  prominently  in  the  negro.     The  first  is  this:  When  the  negro  de- 


TUBERCULOSIS   IN   THE   NEGRO  123 

velops  tuberculosis  it  rarely  leaves  its  victim  alive;  in  other  words,  the 
mortality  is  much  greater  than  among  the  whites.  The  second  pertains 
to  tuberculosis  among  the  mulattoes;  in  these  it  seems  to  be  more  fatal 
than  in  the  full-blood  negroes.  The  medical  profession  of  the  South  is 
unanimous  in  the  opinion  that  in  the  negro's  condition  of  slavery 
tuberculosis  was  comparatively  unknown.  These  facts,  which  are  chiefly 
medical  and  partly  sociologic,  will  explain  the  excessive  death-rate  from 
tuberculosis  in  this  race.  They  will  also  be  suggestive  to  philanthropists 
who  wish  to  benefit  the  negro  and  physicians  in  the  South  Avho  must 
assume  the  duty  of  treating  and  caring  for  them;  for  aside  from  that 
duty  which  falls  to  the  lot  of  every  physician  to  heal  the  sick,  whether 
poor  or  rich,  there  comes  the  additional  call  to  protect  the  innocent. 
WTiile  tuberculosis  exists  as  such  a  scourge  among  the  negroes,  it  is 
plain  that  the  white  population  is  benefited  when  the  disease  is  checked 
in  the  negro,  for  these  people  serve  in  the  households  of  the  whites  as 
nurses,  washerwomen,  cooks,  chambermaids,  etc. 

The  statistics  from  cities  in  both  the  North  and  the  South  cannot 
but  carry  their  lessons,  and  the  philanthropists  who  really  wish  to  ele- 
vate the  race  will  do  better  to  devote  their  money  to  the  erection  of 
hospitals  and  dispensaries  and  instructing  these  people  in  trades,  rather 
than  to  the  erection  and  maintenance  of  colleges  for  the  exploiting  of 
higher  mathematics,  sciences,  and  the  dead  languages,  for  which  the 
present  status  of  the  race  finds  little  or  no  preparation.  The  writer  does 
not  wish  to  be  understood  as  decrying  or  disparaging  the  progress  of 
the  negro.  What  he  has  said  concerning  him  applies  with  even  greater 
force  to  the  Indian,  and  with  less  excuse.  The  negro,  transplanted 
from  his  African  home,  enslaved,  and  finally  freed,  has  become  a  pro- 
ducer; from  this  point  of  view  slavery  was  therefore  to  the  negro  a 
blessing  in  disguise;  the  Indian,  on  the  other  hand,  although  given  or 
allowed  to  retain  lands,  fed  and  pampered  by  a  sentimental  govern- 
ment, is  a  parasite.  The  comparison  is  all  in  favor  of  the  negro, 
but  the  medical  and  sociological  facts  concerning  both  races  remain 
undisturbed.  Since  the  tendency  of  the  negro  is  toward  the  congested 
districts,  the  statistics  concerning  him  are  fuller  and  more  reliable  than 
for  any  other  of  the  dark-skinned  races  except  the  Indian,  who,  like 
a  Government  note,  must  be  accounted  for  by  the  Government,  but 
who,  for  manifest  reasons,  is  not  so  available  for  comparison  as  the 
negro  (see  Fig.  20). 


124 


TUBERCULOSIS   AMONG   THE    DARK-SKINNED   RACES 


Thomas  J.  Jones  ('06)  makes  the  following  observations  to  this 
chart: 

In  the  cities  of  the  South  with  a  negro  population  ranging  from 
twenty-seven  per  cent  in  New  Orleans  to  fifty-six  per  cent  in  Charleston, 
S.  C,  the  death-rate  of  the  negroes  from  consumption  is  two  and  three 
times  that  of  the  whites.  Though  the  proportion  of  negroes  in  Northern 
cities  is  small,  the  actual  niimber  is  quite  large.  New  York  and  Phila- 
delphia, each  with  over  sixty  thousand  negroes,  have  a  very  high  death- 


MORTALITY  FROM  CONSUMPTION  1900 

RATE  PER  HUNDRED-THOUSAND 

NEW  YORK  CITY 
BOSTON 
NASHVILLE 
RURAL  TENN. 
MEMPHIS 
ATLANTA 
RURAL  GA. 
SAVANNAH 
CHARLESTON 
RURAL  S.C. 
MOBILE,  ALA. 
FLORIDA 

NEW  ORLEANS 
RURAL  LA. 
U.S.  CITIES 

RURAL  U.S. 
U.S.  GENERAL 

]00       200       300      400      500       600       700       800| 

M   1   II   1   1   1   1   1 

... 

^M 

M  T 

1  1 

illll 

^m^ 

Ui 

1 

^^^^^^ 

^^^^ 

rtt 

r 

^^ 

^^^1 

4 

T 

"^ 

uT\ 

^ 

^ 

J 

^T 

'1 

Z^ 

■■■■ 

T 

^^^^^ 

^^ 

'Mil! 

^^^T 

^, 

^^^ 

1  1  1  1 

n 

n 

TTnT 

t 

1  1  1  1  1  1 

^111  ! 

WHITE  1          1                           COLO 

REDIHH 

Fig.  20. — Comparative  Mortality  from  Consumption  op  Whites  and  Blacks 
IN  Cities  and  Districts  of  the  United  States.     (Thomas  J.  Jones.) 


rate  from  tuberculosis.  Boston,  with  a  negro  population  of  about  twelve 
thousand,  has  the  highest  rate  of  negro  mortality  from  consumption  of 
any  city  in  the  United  States.  According  to  the  census  of  1900  for  the 
District  of  Columbia,  the  mortality  of  the  87,000  colored  people  from  con- 
sumption was  448,  while  that  for  the  172,000  whites  was  403.  Thus  a 
little  over  half  of  the  total  number  of  deaths  is  credited  to  a  third  of  the 
people.  If,  as  was  stated  in  Charities  for  May  12th,  there  is  one  con- 
sumptive  to    every  one  hundred   Washingtonians,    it   follows   that   there 


TUBERCULOSIS   IN  THE   NEGRO 


125 


are  one  colored  and  one  white  consumptive  to  every  two  hundred  Wash- 
ingtonians. 

In  Charleston,  S.  C,  Augusta  and  Atlanta,  Ga.,  and  Xew  Orleans, 
La.,  typical  cities  of  the  South,  the  mortuary  tables  for  tuberculosis  for 
whites  and  colored  are  as  follows : 


Charleston,  S.  C. 


Deaths  from  Tubercu- 
losis. 

Total  Deaths. 

Population. 

Year. 

White. 

Colored. 

White. 

Colored. 

White. 

Colored. 

1898 

47 

221 

491 

1,258 

28,870 

36,295 

1899 

42 

223 

526 

1,277 

28,870 

36,295 

1900 

40 

194 

484 

1,242 

24,285 

31,522 

1901 

46 

159 

477 

1,149 

24,285 

31,522 

1902 

36 

181 

461 

1,154 

24,285 

31,522 

1903 

53 

165 

426 

1,041 

24,285 

31,522 

1904 

44 

162 

455 

1,089 

24,238 

31,569 

1905 

36 

167 

440 

1,056 

24,238 

31,569 

1906 

33                 159 

442 

1,102 

24,285 

31,522 

1907 

24                  152 

433 

968 

27,470 

29,899 

Year. 

1       White. 

Colored. 

1898 

Ratio  of  deaths  from  tuberculosis  to  total  mortality 

1-10.44 

1-5.69 

1899 

1-12.61 

1-5.72 

1900 

1-12 . 10 

1-6.40 

1901 

1-10.37 

1-7.22 

1902 

1-12.80 

1-6.37 

1903 

1-  8.30 

1-^.30 

1904 

1-10.34 

l-€.78 

1905 

(      (( 

1-12.22 

1-6.32 

1906 

1-13.39 

1-^.93 

1907 

"       " 

1-18.04 

1-6.39 

Augusta,  Ga. 

Deaths  from  Tubercu- 
losis. 

Total  Deaths. 

P0PUL> 

ITION. 

Year. 

White. 

Colored. 

White. 

Colored. 

White. 

Colored. 

1898 

19 

87 

293 

509 

30,435 

19,565 

1899 

31 

94 

366 

530 

30,435 

19,565 

1900 

45       . 

95 

343 

612 

30,435 

19.565 

1901 

28 

112 

317 

600 

22,876 

16,565 

1902 

24 

60 

351 

556 

24,865 

16,576 

1903 

23 

75 

291 

473 

24,465 

16,916 

1904 

35 

70 

340 

522 

26,065 

17,316 

1905 

34 

59 

330 

444 

26,665 

17,716 

1906 

37 

62 

371 

503 

28.000 

19,200 

1907                   39 

64 

386 

449 

29,520 

19,680 

126 


TUBERCULOSIS  AMONG  THE   DARK-SKINNED  RACES 


Augusta,  Ga.,  Continued 


Year. 

White. 

Colored. 

1898 

Ratio  of  deaths  from  tuberculosis  to  total  mortality 

1-15.27 

1-5.83 

1899 

"      "       ' 

1-11.80 

1-5.82 

1900 

1-  7.62 

1-6.44 

1901 

1-11.32 

1-5.32 

1902 

1-14.66 

1-9.26 

1903 

1-12.65 

1-6.30 

1904 

1-  9.71 

1-7.45 

1905 

1-  9.70 

1-7.52 

1906 

1-10.02 

1-8.11 

1907 

"      "       "          "                "            ' 

1-  9.89 

1-6.85 

In  other  words,  though  the  colored  population  is  ten  per  cent  to  six- 
teen per  cent  less  than  the  white,  in  ten  years  tuherculosis  carried  off 
778  white  persons  and  315  colored.  In  round  numbers,  allowing  for 
the  discrepancy  in  population,  about  twice  as  many  colored  people  die 
annually  from  tuberculosis  as  in  the  white  race. 

Atlanta,  Ga. 


Year. 

Deaths  from  Tubercu- 
losis. 

Total  Deaths. 

Population. 

White. 

Colored. 

White. 

Colored. 

White. 

Colored. 

1899 
1900 
1901 
1902 
1903 
1904 
1905 
1906 
1907 

97 

80 

87 

110 

88 

115 

108 

111 

114 

148 
134 
135 
153 
133 
165 
171 
161 
114 

1,045 

916 

914 

979 

926 

1,053 

1,128 

1,182 

1,275 

1,197 
1,014 
1,227 
1,092 
1,015 
1,253 
1,206 
1,299 
1,258 

75,000 
79,000 
82,000 
60,000 
66,000 
72,000 
75,000 
80,000 
85,000 

50,000 
52,000 
53,000 
40,000 
44,000 
48.000 
50,000 
55,000 
55,000 

Year. 

White. 

Colored. 

1899 
1900 
1901 
1902 
1903 
1904 
1905 
1906 
1907 

Ratio  of  deaths  from  tuberculosis  to  total  mortality. 

Same  ratio  of  whites  would  give  death-rate  222. 
Ratio  of  deaths  from  tuberculosis  to  total  mortality. 

Same  ratio  would  give  white  mortality  203. 
Ratio  of  deaths  from  tuberculosis  to  total  mortality. 

Same  ratio  would  give  white  mortality  208. 
Ratio  of  deaths  from  tuberculosis  to  total  mortahty. 

Same  ratio  of  whites  would  give  death-rate  229. 
Ratio  of  deaths  from  tuberculosis  to  total  mortaUty. 

Same  ratio  of  whites  would  give  death-rate  201. 
Ratio  of  deaths  from  tuberculosis  to  total  mortality. 

Same  ratio  of  whites  would  give  death-rate  247. 
Ratio  of  deaths  from  tuberculosis  to  total  mortality. 

Same  ratio  of  whites  would  give  death-rate  256. 
Ratio  of  deaths  from  tuberculosis  to  total  mortality. 

Same  ratio  of  whites  would  give  death-rate  234. 
Ratio  of  deaths  from  tuberculosis  to  total  mortality. 

Same  ratio  of  whites  would  give  death-rate  176. 

1-10.77 
1-11.45 
1-10.50 
1-  8.09 
1-10.52 
1-  9.15 
1-10.44 
1-10.64 
1-11.19 

1-  8.08 
1-  7.56 
1-  9.06 
1-  7.15 
1-  7.63 
1-  7.59 
1-  7.05 
1-  8.44 
1-11.03 

TUBERCULOSIS   IX   THE    INDIAN 


127 


New  Oklean.s,  La. 


Year. 

Deaths  from  Tubercu- 
losis. 

Total  Deaths.                           Population. 

White. 

Colored. 

White. 

Colored.            White.              Colored. 

1897 
1898 
1899 
1900 
1901 
1902 
1903 
1904 
1905 
1906 
1907 

405 
546 
544 
512 
483 
549 
549 
578 
540 
499 
575 

454 
447 
490 
500 
452 
494 
504 
564 
543 
483 
480 

4,268 
4,275 
4,913 
4,318 
4,037 
4,067 
4,200 
4,222 
4,689 
4.150 
4,665 

4,462 
2,551 
2,980 
3,106 
2,441 
2,505 
2,505 
2,597 
2,640 
2,668 
2,968 

195,000 
195,000 
210,000 
210,000 
210,000 
227,000 
233,000 
239,000 
245,000 
251,000 
258,000 

80,000 
80,000 
90,000 
90,000 
90,000 
83,000 
84,000 
86.000 
88,000 
90,000 
93,000 

Cases  of  hemoptysis  included. 


Pneumonic  tuberculosis  included. 


Year. 

White. 

Colored. 

1897 

Ratio  of  deaths  from  tuberculosis  to  total  mortality 

1-10.53 

1-9.82 

1898 

1-  7.82 

1-5.70 

1899 

1-  9.03 

1-6.08 

1900 

1-  8.43 

1-6.21 

1901 

1-  8.35 

1-5.40 

1902 

1-  7.22 

1-5.07 

1903 

1-  7.46 

1-4.95 

1904 

1-  7.47 

1-4.60 

1905 

1-  8.68 

1-4.86 

1906 

1-  8.31 

1-5 . 85 

1907 

1-  8.11 

1-6.18 

TUBERCULOSIS    IN    THE    INDIAN 

It  is  generally  conceded  that  pulmonar}'  tuberculo-sis  was  not  known 
to  the  Indian  in  his  barbaric  state — at  least,  that  it  was  a  disease  of 
rare  occurrence.  The  Indian  is  of  a  face  of  people  over  whom  our 
Government  has  felt  it  needful  to  keep  an  accurate  supervision.  The 
physicians  who  have  cared  for  them  have,  for  the  most  part,  been 
selected.  Their  positions  have  demanded  that  they  make  an  accurate 
report  of  their  stewardship.  The  reports,  therefore,  of  the  sanitary 
condition  of  this  race  are  more  perfect  than  for  any  race  in  America. 
For  the  Indians,  then,  they  may  be  accepted  as  approximately  accurate. 
There  has  been  an  impression  both  among  the  laity  and  the  medical 
profession  that  tuberculosis  is  a  scourge  of  this  race  since  its  contact 
with  the  white  man,  and  an  inquiry  into  its  history  is  essential  to  fix 
the  accuracy  of  this  conclusion. 


128         TUBERCULOSIS  AMONG  THE  DARK-SKINNED  RACES 

Dr.  James  Jl.  Walker  ('06),  of  Pine  Ridge,  Soutli  Dakota,  states 
that : 

Tuberculosis  existed  among  these  Indians  before  they  came  into  con- 
tact with  the  white  people,  but  at  that  time  the  disease  was  rare  among 
them  and  remained  so  until  they  changed  their  nomadic  to  a  settled  life 
in  houses.  When  they  began  to  live  in  houses,  tuberculosis  began  to 
increase  among  them,  so  that  the  conditions  which  caused  this  increase 
must  have  been  different  from  those  surrounding  them  when  they  lived 
in  tepees.  They  were  filthy  both  when  they  lived  in  tepees  and  when  they 
lived  in  houses.  It  was  statistically  demonstrated  that  those  who  were 
most  cleanly  were  less  liable  to  infection  by  any  disease  than  were  the 
most  filthy;  and,  conversely,  that  the  most  filthy  were  most  liable  to 
infection  of  every  kind. 

In  1896  it  was  asserted  that  more  than  one  half  of  the  Oglalas  were 
tuberculous,  and  that  more  than  seventy-five  per  cent  of  the  total  deaths 
among  them  were  caused  by  this  disease.  This  was  an  exaggeration  that 
is  common  in  discussing  tuberculosis  among  the  Indians.  The  facts  were 
that  there  were  at  that  time  4,893  Oglalas,  of  whom  741  were  tuberculous, 
and  of  these  124  died  that  year.  That  is,  148.7  per  1,000  were  tubercu- 
lous, and  the  annual  death-rate  from  this  disease  was  24.88  per  1,000. 
As  the  entire  annual  death-rate  was  52.88  per  1,000,  the  deaths  from 
tuberculosis  were  but  forty-seven  per  cent  of  this. 

But  this  death-rate  was  appalling,  for  the  annual  birth-rate  was  but 
41.54  per  1,000,  which  showed  a  decrease  of  11.64  per  1,000  because  of  the 
excess  of  the  death-rate  over  the  birth-rate.  As  the  percentage  of  deaths 
from  tuberculosis  was  so  great,  this  disease  was  exterminating  this  people. 

Dr.  I.  W.  Brewer,  of  Fort  Chiliuahua,  Ariz.,  has  made  a  careful 
study  of  the  Indians  of  the  Southwest.  Woods  Hutchinson  ('07)  sums 
up  his  findings  as  follows: 

Among  the  Mojaves  tuberculosis  was  responsible  for  ninety-five  per 
cent  of  the  deaths.  Among  the  Hopis  and  Navajos  it  was,  according  to 
one  agency  physician,  "  very  prevalent,"  and  according  to  another.  Dr. 
Parshell,  "  the  greatest  cause  of  death  in  children."  On  another  Navajo 
reservation  it  was  reported  as  "  not  very  prevalent,  but  always  fatal." 
Among  the  Apaches  it  had  "  gained  a  strong  hold."  Among  the  Pimas 
and  the  Maricopas  it  caused  sixty-six  per  cent  of  the  deaths.  Among  the 
Havasupi  and  Walapai  it  caused  seventy-five  per  cent  of  the  deaths ;  on 
another,  sixty  per  cent.  Among  the  Pueblo  Indians  at  Santa  Fe  it  was 
"  rare,  less  frequent  than  with  other  Indians."  Among  the  Zunis  the 
actual  amount  was  small,  "but  the  mortality  one  hundred  per  cent."  The 
average,  from  the  percentages  actually  given  in  these  cases,  was  seventy- 
two  per  cent  of  all  the  deaths.  This,  with  my  Northern  studies,  pretty 
well  covered  the  Indians  of  the  Pacific  Northwest  and  of  the  Coast  and 
most  of  the  great  Southwest. 


TUBERCULOSIS  AMONG   THE   JAPANESE   AND   CHINESE       129 

At  the  Black  Feet  agency  Dr.  George  Martin  reports  that  "  sixty- 
seven  per  cent  of  the  deaths  were  dne  to  that  disease  in  that  year." 

From  tlie  Crow  Creek  agency,  in  South  Dakota,  Dj-.  J.  Silverstein 
reports  that  "  most  of  tlie  deaths  are  due  to  this  cause." 

Among  the  Rosebud  Sioux  Dr.  W.  H.  Harrison  decLares  it  to  be 
"the  greatest  menace  to  the  health  of  the  tribe."     (Hutchinson,  '07.) 

To  Sum  up. — On  nine  reservations  where  the  actual  figures  are 
given,  the  average  proportion  of  deaths  due  to  this  disease  is  sixty-six 
per  cent.  When  one  attempts  to  explain  this  enormous  death-rate  he 
is  confronted  with  much  the  same  conditions  as  the  negro  presents,  only 
in  a  more  exaggerated  form.  The  inclination  of  the  Indian  to  dissi- 
pation and  his  disinclination  to  work,  his  filthy  habits,  his  ignorance 
and  utter  disregard  of  the  laws  of  hygiene,  and  finally  his  lack  of  im- 
munity and  racial  predisposition — all  account  for  the  enormous  death- 
rate  among  them  from  tuberculosis. 

TUBERCULOSIS    AMONG    THE    JAPANESE    AND    CHINESE 

Statistics  are  often  misleading  when  accurately  kept.  When  inac- 
curately kept  they  are  worthless.  With  medicine  occupying  the  place 
it  has  in  Japan  and  China  throughout  all  recorded  history,  it  is  clear 
that  little  can  be  expected  from  a  statistical  study  of  this  disease  in 
these  countries.  It  is  a  matter  of  common  observation  that  Chinese  and 
Japanese  who  come  to  this  country  are  especially  lia])le  to  contract 
tuberculosis,  and  such  statistics  as  are  recorded  show  a  relatively  high 
mortality  for  these  races  as  compared  with  our  native  white  populations. 
The  United  States  Census  for  1900  gives  the  death-rate  of  239  per 
100,000  living  Japanese,  as  compared  with  173  in  the  white  population. 
Hutchinson  states  that  "  in  the  Portland  and  San  Francisco  China- 
towns the  mortality  was  more  than  double  that  of  the  surrounding 
white  population,"  and  the  United  States  Census  for  1900  gives  658.5 
per  100,000  living,  nearly  four  times  that  of  the  general  white  popu- 
lation. 

The  cause  for  this  a])palling  death-rate  will  be  readily  apparent,  par- 
ticularly in  the  case  of  the  Chinese.  To  begin  with,  we  have  brought 
to  our  shores  a  new  and  relatively  susceptil)le  race  of  jteople.  They 
are  densely  ignorant  and  utterly  disregardful  of  the  finidamental  laws 
of  hygiene.  They  represent  the  lowest  grade  of  citizenship  in  their  own 
densely  benighted  land.  Their  intelligence  is  sufficient  to  make  them 
hold  to  two  purposes,  viz.,  the  preservation  of  the  cue,  which  is  the 
"open  sesame"  to  the  Chinese  Fmpire,  and  the  accumulation  of  suf- 
ficient money  to  live  out  their  remaining  days  in  China  without  further 

work  when  they  return  home. 
10 


180         TFBERCrLOSIS   AMONG  THE   DARK-SKINNED  RACES 

Xcither  the  prcsci-vjitiitn  of  tli('  cue  nor  llx-  aceumulatioi)  of  wealth 
are  ignoble,  nor  do  they  concern  ns,  beyond  the  inroads  which  the 
acquisition  of  the  latter  make  on  the  races.  The  average  Chinaman 
coming  to  this  country  was  of  the  coolie  class,  therefore  too  much 
should  not  be  expected  of  him,  but  liis  menace  to  his  immediate  neigh- 
bors does  concern  us.  The  writer  believes  that  they  are  in  this  country 
cleanly  of  body  and  careful  of  what  they  eat;  they  are  also  industrious, 
probably  beyond  reason.  This  is  unquestionably  to  their  credit,  and  if 
that  were  all,  these  people  would  make  a  desirable  instead  of  an  unde- 
siralile  citizenship.  When  one  passes  to  the  other  phases  of  their  char- 
acter he  does  not  wonder  at  the  amount  of  tuberculosis  that  is  ])revalent 
among  them. 

Notoriously  and  ahead  of  all  the  other  dark-skinned  races  is  the 
Chinaman  given  over  to  dissipation  and  vice.  He  cares  nothing  for 
the  comforts  or  restraints  of  the  home.  (Jambling  is  his  pastime;  he 
inclines  to  sexual  excess;  as  a  race  he  is  addicted  to  tlie  opium  habit, 
and  to  this  in  America  he  often  adds  alcohol;  finally,  where  their  least 
discretion  is  shown  is  in  their  sleeping  apartments.  Ventilation  is  a 
thing  unknown  to  them,  and  a  not  unusual  sleeping  apartment  in  the 
Chinatowns  of  this  country  is  four  l)v  eight  feet.  T'sually  there  is  a 
gathering  room,  but  this  only  increases  the  liability  to  infection,  not 
only  from  their  numbers,  which  make  the  air  foul,  l)ut  in  addition  from 
their  expectoration  on  the  floors  and  their  general  unhygienic  behavior. 


CHAPTER    III 

FREQUENCY   OF   TUBERCULOSIS    IN   INSANE   ASYLUMS 
By  RICHARD   H.   HUTCHINGS 


ATTE:\rPTS  to  arrive  at  an  accurate  estimate  of  the  number  of  the 
insane  in  custody  who  are  tuberculous  have  not  achieved  satisfactory 
results.  But  little  has  been  published  bearing  on  this  point.  The  New 
York  State  Commission  in  Lunacy,  in  1904,  estimated  that  there  were 
among  the  25,000  insane  in  custody  in  that  State  500  cases  of  tuber- 
culosis, a  ratio  of  two  per  cent.  Dr.  i\[ott  investigated  the  question  in 
the  London  County  Asylums  and  estimated  the  ratio  of  tuberculosis 
at  1.72.     (F.  Peterson,  'OL) 

At  the  St.  Lawrence  State  Hospital.  Ogdensburg,  N.  Y.,  in  1904, 
a  careful  physical  examination  of  the  entire  population,  amounting  at 
that  time  to  1.T20,  revealed  T8  cases  of  tuberculosis  of  the  lungs  of 
greater  or  less  degree.  In  this  test  tuberculin  was  not  employed.  This 
percentage  is  4.5.  In  the  Middletown  State  Hospital,  Middletown, 
N.  Y.,  there  has  been  constantly  for  the  past  fifteen  years  about  three 
per  cent  of  recognized  tuberculosis,  according  to  a  statement  of  Dr. 
Ashley,  the  superintendent.  Some  very  notable  investigations  on  this 
subject  have  been  made  by  Dr.  W.  F.  Menzies,  who  examined  647 
patients,  the  entire  population  of  the  Staffordshire  County  Asylum  in 
1905,  and  found  positive  physical  signs  of  tuberculous  disease  in  123 
and  doubtful  signs  in  133.    He  gives  the  accompanying  table,  showing  a 


Admitted  during  the  year 

Admitted  with  positive  physical  signs. . .  . 
Admitted  with  doubtful  physical  signs. . . 

Admitted  who  reacted  to  tuberculin 

Deaths  from  tuberculosis 

Other  P.M's  disclosing  active  tubercle 

Other  P.M's  disclosing  healed  tubercle. .  . 
Examined  with  positive  physical  signs. . . 
Examined  with  doubtful  physical  signs.. . 
Examined  who  are  probably  tuberculous. 


Numbf;rs. 


98 
13 
11 
76 
13 
4 
16 
77 
56 


80 

6 

4 

60 

8 

0 

10 

46 

77 


178 

19 

15 

136 

21 

4 

26 

123 

133 

348 


Percentage  on  Averagk 
Numbers  Resident. 


7.54 
23.90 
5.34 
5.03 
42.5 


3 
17.01 

2.38 

3 
36.82 


5.20 

20.82 

3.82 

3.98 

39.56 

53.78 


131 


132       FREQUENCY   OF   TUBERCULOSIS  IN   INSANE  ASYLUMS 

year's  statistics  of  tuberculosis  in  that  institution  with  a  population  of 
647.1 

Thougli  l)ut  little  lias  been  i)ublishecl  in  regard  to  the  frequency  of 
tuberculosis  in  the  population  of  hospitals  for  the  insane,  some  idea  of 
its  frequency  can  be  gained  from  the  mortality  from  this  disease.  In 
a  report  of  the  New  York  State  Commission  in  Lunacy  for  the  year 
ending  September  30,  1906,  it  was  reported  that  the  deaths  from  all 
causes  from  October  1,  1888,  to  September  30,  1906,  in  the  Xew  York 
State  hospitals  had  tjeen  28,106.  Of  these,  4,059  have  been  from  tuber- 
culosis, a  ratio  of  14.4  per  cent.  In  the  annual  report  of  the  Govern- 
ment Hospital  for  the  Insane,  Washington,  D.  C,  for  the  year  ending 
June  30,  1906,  Dr.  William  White,  the  superintendent,  gives  a  state- 
ment of  deaths  from  tuberculosis  occurring  in  that  institution  during 
the  twenty-one  years  (1885-1906)  inclusive.  During  this  period  there 
were  3,746  deaths  from  all  causes,  of  which  2,103  were  examined  into 
post  mortem.  Active  tuberculous  disease  was  found  post  mortem  in 
432  cases;  latent  or  limited  tuberculosis,  post  mortem,  in  586  cases. 
There  were  also  during  that  time  236  deaths  from  tuberculosis,  in 
which  the  diagnosis  was  based  on  clinical  signs  and  not  verified  post 
mortem.  Total  of  all  cases  of  death  from  pulmonary  tuberculosis, 
clinical  and  post  mortem,  822.  Percentage  of  tu1)erculous  cases  among 
those  tliat  died,  recognized  clinically  and  at  autopsy,  21.9.  Per- 
centage of  those  examined  post  mortem  which  showed  tuberculous 
lesions,  27.08. 

From  the  seventeenth  annual  report  of  tlie  Asylums  Committee  of 
the  London  County  Council  there  were  1.481  deaths,  of  which  164  were 
attributed  to  tuberculosis.  The  number  of  post  mortems  is  not  stated. 
Dr.  Menzies,  superintendent  of  the  Staffordshire  Asylum,  states  that 
of  the  post  inortems  68  per  cent  showed  gross  signs  of  old  or  recent 
tubercle,  and  of  51  cases  of  tu])erculosis  proved  by  post  mortem  exami- 
nation, 26  had  definitely  recovered  long  previously.  The  State  Board 
of  Insanity  of  Massachusetts  reported  in  1905  that  of  the  deaths  in 
the  institutions  for  the  insane  in  that  State  during  the  preceding  year, 
14.27  per  cent  were  caused  by  tuberculosis.  In  the  annual  report  of 
the  New  York  State  Department  of  Health  for  the  year  ending  Decem- 
ber 31,  1906,  the  total  deaths  from  all  causes  throughout  the  State  were 
140,343.  Of  these,  14,027  were  due  to  consumption,  a  ratio  of  1  to  10; 
while  during  the  same  year  there  were  in  the  hospitals  for  the  insane 
in  New  York  2,071  deaths,  of  which  345  were  attributed  to  tuberculosis, 
or  16.6  per  cent. 

»  Annual  Report,  1905-1906,  p.  18. 


TUBERCULOSIS  IN   HOSPITALS  FOR  THE  INSANE  133 

TUBERCULOSIS   IN   HOSPITALS   FOR   THE   INSANE 

That  this  disease  prevails  to  an  alarming  degree  in  institutions  for 
the  insane  is  conceded.  Its  frequency  varies  in  different  institutions 
and  in  the  different  wards  of  the  same  institution.  It  is  the  experience 
of  the  writer  that  tliere  are  certain  wards  in  which  a  case  of  tuljerculosis 
has  not  developed  in  more  than  eleven  years,  and  other  wards  which 
yield  one  or  more  cases  every  year. 

The  wards  in  which  the  disease  occurs  with  greatest  frequency  are 
those  occupied  hy  the  most  demented  class  of  patients.  These,  by  reason 
o.f  their  mental  condition,  cannot  be  usefully  employed ;  but,  on  the  con- 
trary, they  lead  sedentary  and  inactive  lives.  Many  of  them  are  so 
stupid  that  any  voluntary  effort  is  practically  abolished,  and  they  sit 
in  one  attitude  for  hours  at  a  time  and  until  recjuired  to  change  their 
position.  These  are  the  wards  in  large  public  institutions  which  tend 
to  become  overcrowded,  even  wlien  in  the  institution,  as  a  whole,  the 
overcrowding  is  not  serious.  The  so-called  untidy  wards  are  very  apt 
to  be  badly  overcrowded  both  day  and  night.  The  fact  that  the  wards 
are  crowded  rendei's  rather  urgent  the  necessity  of  keeping  people  in 
their  places,  and  the  requirement  of  good  order,  as  construed  by  the 
attendants  and  nurses,  is  to  have  each  patient  seated  quietly  in  his  place 
and  to  discourage  all  motor  activity.  The  ventilation  under  these  cir- 
cumstances is  rarely  good,  and  when  patients  spend  weeks  and  months, 
and  sometimes  years,  in  a  ward  of  this  character,  it  is  not  surprising 
that  many  of  them  succumb  to  tuberculosis. 

Many  of  these  patients  are  of  untidy  and  careless  habits.  They  pick 
up  from  the  floor  strings  and  small  objects  of  any  kind  and  put  them  into 
their  mouths,  and  even  in  some  cases  the  contents  of  cuspidors  find  their 
way  into  the  patients'  mouths.  The  mere  fact  of  patients  being  crowded 
together  appears  to  predispose  them  to  tuberculosis,  even  where  the  ven- 
tilation is  regarded  as  good  and  the  housekeeping  is  above  criticism. 

Dr.  Menzies,  in  a  report  already  quoted,  speaking  of  his  experience 
with  tuberculosis  and  dysentery,  says: 

Although  it  is  difficult  to  say  how  overcrowding  can  cause  disease, 
provided  cleanliness  and  thorough  ventilation  are  properly  attended  to, 
still  the  fact  remains  that  dysentery,  erysipelas,  and  tuberculosis  always 
increase  in  overcrowded  asylums,  and  one  is  driven  to  the  conclusion  that 
infection  occurs  more  easily  because  the  patients  are  actually  placed 
closer  together,  and  not  because  the  overcrowding  i)roduces  less  efficient 
attention  to  the  ventilation  and  t-leanliness  of  the  wards  and  patients. 

Those  })atients  wlio  canlx;  employed,  and  who,  therefore,  are  off  the 
ward  a  portion  or  a  greater  part  of  each  day,  unless  crowded  in  sewing 


134       FREQUENCY   OF   TUBERCULOSIS  IN   INSANE  ASYLUMS 

rooms  or  sliops,  are  usually  in  liiueli  healthier  eondition  and  freer  I'roni 
tuberculosis  than  those  remaining  in  the  ward  unemployed.  At  the  St. 
Lawrence  State  Hospital  there  are  two  detached  cottages,  accommodating 
together  140  patients,  who  are  employed  at  garden  and  farm  work,  and 
during  the  past  eleven  years  not  a  single  case  of  tuberculosis  has  occurred 
in  any  of  these  patients,  though  the  disease  has  shown  a  steady  increase 
in  the  institution  as  a  whole.  As  most  institutions  for  the  insane  have 
farms  or  large  gardens  attached,  it  is  comparatively  easy  to  find  suit- 
able employment  out  of  doors  for  men,  and  difficult  to  find  work  for 
the  women,  except  housework  and  indoor  occupations,  such  as  sewing, 
rug-making,  chair-caning,  and  other  more  or  less  sedentary  occupations. 
Let  us  see  how  the  prevalence  of  tuberculosis  differs  in  the  two  sexes 
on  account  of  this  well-recognized  difference  in  the  employment  of  our 
hospital  inmates : 

In  the  period  1888-1906,  according  to  the  report  of  the  New  York 
State  Commission  in  Lunacy,  there  were  reported  28,106  deaths  from 
all  causes,  of  which  15,<?42  were  among  men  and  12,864  were  among 
women.  Among  the  men  the  deaths  from  tuberculosis  were  1,463,  or 
9.5  per  cent,  while  the  deaths  from  tuberculosis  among  the  women  were 
2,596,  or  20.1  per  cent — more  than  twice  as  many  deaths  among  the 
women  as  among  the  men.  The  mortality  among  the  men  from  this 
disease  is  no  higher  than  that  of  tlic  State  at  large,  whereas  that  for  the 
women  is  more  than  twice  the  mortality  of  tlie  State  at  large  and  more 
than  twice  that  of  the  men  treated  in  the  same  institutions. 

It  would,  therefore,  seem  clear  that  the  extreme  susceptibility  to 
tuberculosis  among  the  insane  is  confined  to  the  demented  and  inactive 
classes,  and  is  probably  due  to  the  overcrowding,  bad  air,  and  lack  of 
outdoor  employment. 

DIAGNOSIS   OF   TUBERCULOSIS   IN   THE   INSANE 

Tuberculosis  occurs  with  the  greatest  frequency  among  the  demented 
and  untidy  class  of  patients.  In  these  it  is  not  infrequent  for  the  dis- 
ease to  become  well  established  before  the  cough  is  noticed.  This  is 
probably  due  to  two  causes:  (1)  A  voluntary  suppression  of  the  cough 
by  the  patient  in  some  cases;  (2)  in  others  the  irritation  in  the  bronchi 
does  not  appear  to  be  sufficient  to  provoke  a  cough.  It  not  infrequently 
happens  under  competent  observation  that  a  case  advances  to  a  consid- 
erable degree  of  consolidation  before  it  is  even  suspected.  Indeed,  such 
patients  cannot  coo])erate  with  the  examiner  in  bringing  out  obscure 
physical  signs.  Consolidation  is  the  first  objective  sign  which  can  be 
elicited  in  many  cases.  Now  that  the  use  of  tuberculin  has  l)een  sim- 
plified by  the  introduction  of  the  ophthalmic  reaction,  the  early  diag- 


TREATMENT   OF   TUBERCULOSIS   IX   THE   INSANE  135 

uosis  of  this  disease  among  the  insane  will  be  greatly  facilitated,  and  in 
those  wards  in  which  experience  has  shown  the  disease  most  frequently 
develops  the  patients  should  be  tested  from  time  to  time. 

TREATMENT   OF   TUBERCULOSIS  IN   THE   INSANE 

Prevention  of  Tuberculosis. — It  is  now  generally  recognized  that 
among  the  insane,  as  elsewhere,  tuberculous  patients  should  be  removed 
from  contact  with  the  healthy  and  afforded  the  treatment,  as  far  as 
possible,  which  is  now  recognized  to  be  the  most  appropriate  for  all 
tuberculous  affections.  To  this  end,  all  patients,  at  the  time  of  admis- 
sion to  hospitals  for  the  insane,  should  be  examined  carefully  for  the 
presence  of  this  disease,  and  Avhen  the  condition  of  the  patient  is  such 
that  it  cannot  definitely  be  excluded  by  examination  of  the  lungs,  the 
use  of  tuberculin,  preferably  the  ophthalmic  reaction,  should  be  resorted 
to  in  ever}'  case. 

Overcrowding  of  wards  and  dormitories  should  be  avoided,  and  par- 
ticularly those  wards  occupied  by  the  demented  and  inactive  classes. 
In  these  wards  the  patients  should  be  dressed  warmly  and  fresh  air 
should  be  admitted  in  such  quantities  as  to  effectually  do  away  with  all 
foul  air  in  the  wards.  All  patients  physically  able  should  be  exercised 
and,  if  possible,  employed  in  the  open  air  daily.  The  clothing  worn  by 
one  patient  should  not  be  worn  by  another  until  it  has  been  disinfected. 
The  danger  here  is  particularly  in  the  use  of  shawls,  hoods,  and  wraps 
for  the  neck.  A  bed  that  has  been  occupied  by  one  patient  should  not 
be  used  by  another  until  the  bedding  has  been  disinfected. 

The  use  of  drinking  cups  attached  to  ice-water  tanks  should  be  done 
away  with,  and  drinking  fountains,  such  as  are  now  in  use  quite  gen- 
erally in  public  buildings  and  schools,  should  be  substituted.  A  room 
occupied  by  a  patient  known  to  be  infected  should  be  fumigated  before 
another  patient  is  assigned  to  it. 

Individual  Treatment. — ^Yhere  it  is  possible  to  do  so,  tuberculous 
patients  should  l)e  segregated  and  cared  for  in  a  pavilion,  where  the  same 
treatment  can  be  given  as  in  sanatoria  generally.  Such  pavilions  have 
been  in  use  at  the  Binghamton  State  Hospital  and  the  St.  Lawrence 
State  Hospital  for  four  years  and  two  and  a  half  years  respectively, 
and  their  operation  has  been  attended  with  no  unfavorafjle  results  on 
account  of  the  mental  condition  of  the  patients.  On  the  contrary,  the 
results  have  been  in  every  way  satisfactory.  The  insane,  particularly 
of  the  class  in  wliich  tuberculosis  is  most  common,  adapt  themselves 
rather  readily  to  the  routine  of  such  an  institution,  and  their  care  offers 
no  insu|)erable  diiricuities  in  the  great  nuijority  of  cases. 

A  hirgci'  |)i()j)()rlion  of  nui'ses  is  required  to  give  them  proper  su|»ei-- 


136       FREQUENCY   OF  TUBERCULOSIS  IN   INSANE  ASYLUMS 

vision  than  in  the  ordinary  asylum  wards,  but  it  should  be  borne  in 
mind  that,  as  a  class,  they  are  liable  to  certain  dangers  which  need  not 
be  considered  in  an  ordinary  sanatorium.  In  cold  weather  they  are  apt 
to  get  the  clothing  disarranged,  suffer  unduly  from  cold,  and  even  to 
have  exposed  portions  of  their  body  frozen  without  complaining.  Others 
may  wander  al)out  and  come  to  harm.  In  others  a  tendency  to  sui- 
cide or  homicide  may  be  present,  wliich  should  carefully  be  guarded 
against. 

The  patients  should  be  so  classified  that  those  who  require  but  little 
attention,  or  can  care  for  themselves,  will  be  together  in  one  ward  or 
in  one  group,  while  those  who  require  the  maximum  of  care  will  be 
kept  together  and  particular  provision  made  for  their  supervision.  In 
this  way  a  few  who  require  it  may  have  the  undivided  attention  of  one  or 


Fig.  21. — Treatment  of  the  Tuberculous  Insane  on  an  Open  Pouch. 
(Winter  of  1903,  St.  Lawrence  State  Hospital,  Ogdensburg,  N.  Y.) 


more  nurses,  as  may  be  necessary,  to  carry  out  the  plan  of  treatment  and 
prevent  reinfection  and  other  dangers  referred  to.  In  general  terms,  it 
may  be  said  that  one  nurse  may  give  proper  attention,  on  an  average,  to 
five  patients  during  the  day,  and  four  times  that  number  at  night. 

Many  of  the  insane,  as  has  been  observed  in  children,  have  a  tend- 
ency to  swallow  their  simtum,  yet  the  more  intelligent  can  be  trained 


TREATMENT   OF   TUBERCULOSIS   IN   THE   INSANE 


137 


to  use  a  sputum  cup.  A  certain  number  will  persist  in  expectorating  on 
their  clothing  or  on  the  floor.  Such  patients  should  be  surrounded  by 
rugs  or  sheets  spread  on  the  floor  and 
moistened  with  an  antiseptic  solution, 
and  these  rugs  should  be  sterilized  fre- 
quently by  boiling.  For  an  exceptional 
few  who,  by  reason  of  delusions,  will 
circumvent  such  simple  precautions, 
well-ventilated  single  rooms  should  be 
provided,  which  will  permit  of  easy 
and  perfect  sterilization. 

For  those  who  refuse  food,  the 
stomach-tube  should  be  used  not  less 
than  three,  and  preferably  four  or  five, 
times  a  day.  Milk  and  eggs  form  the 
staple  article  of  liquid  diet  used  in 
such  cases,  which  should  be  supple- 
mented with  beef  juice,  barley  or  cereal 
water,  sugar,  and  occasionally  fruit 
juices.  Where  a  separate  pavilion  can- 
not be  provided,  excellent  results  have 
been  ol)tained  by  segregating  the  tu- 
berculous insane  in  tents,  as  is  done 
at  tlie  Manhattan  State  Hospital  and 
the  Willard  State  Hospital  in  New 
York. 

Dr.  A.  E.  McDonald,  Superintend- 
ent of  the  ^Manhattan  State  Hospital, 
New  York,  was  the  first  to  treat  in- 
sane tuberculous  patients  by  means  of 
camp  life. 


Fig.  22.  —  A  Cold-proof  Sleep- 
ing-bag AND  Method  of  Ad- 
justment. (Winter,  1903,  St. 
Lawrence  State  Hospital,  Og- 
densburg,  N.  Y.) 


That  consumptive  insane  patients  may  be  kept  and  treated  to  their 
advantage,  and  incidentally  to  the  advantage  of  their  fellow  inmates,  in 
canvas  tents,  and  throughout  the  several  seasons  of  the  year,  would 
appear  to  have  been  demonstrated  in  the  recent  history  of  this  hospital. 
The  experiment  upon  the  success  of  which  this  claim  is  advanced  has, 
at  the  date  of  this  writing,  covered  a  period  of  forty  months. 

The  first  intention  and  expectation  were  that,  by  possibility,  the  con- 
sumptive insane  patients,  or  a  majority  of  them,  might  be  removed  from 
contact  with  their  fellows  for  some  months,  perhaps  as  many  as  five 
months,  during  the  milder  season  of  the  year,  with  the  attendant  advan- 
tage of  freeing  for  the  time  being  corresponding  space  in  the  permanent 
building  and  affording  opportunity  for  disinfection  and  renovation.  As 
11 


138       FREQUENCY   OF   TUBERCULOSIS  IN   INSANE  ASYLUMS 

the  weeks  passed,  however,  and  the  patients  continued  comfortable  (the 
tents  were  heated  with  large  stoves  in  cold  weather),  evacuation  was 
deferred  until  a  severe  storm  occurred.  Then  it  was  that,  in  spite  of  high 
wind  and  snow,  a  more  equable  temperature  had  been  maintained  and 
less  discomfort  caused  in  the  tents  than  in  the  hospital  wards  most 
exposed  to  the  force  of  the  gale.  From  that  experience,  followed  by  other 
confirmatory  ones,  resulted  the  reconsideration  of  the  design -to  evacuate 
the  camp. 


Fig.  23. — Treatment  of  the  Tuberculous  Insane  in  a  Solarium  Warmed  by 
Steam  but  with  Windows  Raised.  (Winter  of  1903,  St.  Lawrence  State  Hos- 
pital, Ogdensburg,  N.  Y.) 

The  isolation  of  the  tuberculous  patients  has  reduced  to  a  minimum 
the  danger  of  infection  of  other  patients  and  of  employees.  The  patients 
themselves  have  suffered  no  injury  or  hardship,  but  have,  on  the  contrary, 
been  unmistakably  benefited.  This  is  shown,  amoftg  other  ways,  by  a 
decrease  in  the  death-rate  from  pulmonary  tuberculosis,  both  absolute 
and  relative,  and  by  a  marked  general  increase  in  bodily  weight,  amount- 
ing in  the  case  of  one  patient  to  an  actual  doubling  of  the  weight — from 
eighty-three  to  one  hundred  and  sixty-six  pounds — in  fourteen  months  of 
camp  residence. 

As  an  interesting  incidental  fact  it  may  be  mentioned  that  not  only 
the  patients,  but  also  the  nurses  living  in  the  camp,  have  enjoyed  almost 
complete  immunity  from  other  pulmonary  diseases;  not  a  single  case  of 
pneumonia  has  developed  in  the  camp  in  its  existence  of  over  three  years, 
though  it  caused  131  deaths  in  the  hospital  proper  in  that  time.^ 

1  Ninth  Annual  Report  of  the  Manhattan  State  Hospital,  New  York  City,  1904. 


PART   III 
SYMPTOMATOLOGY   AND    DIAGNOSIS 


INTRODUCTION 

TUBERCULOSIS    IN    CHILDHOOD  i 
By  CLEMENS  VON  PIRQUET 

The  diagnosis  "  tuberculosis  "  thirty  years  ago  was  equal  to  a  death 
sentence.  In  the  following  years  a  milder  prognosis  was  made — it  was 
said  that  death  could  be  delayed  in  especially  favorable  climatic  sur- 
roundings. Still  some  years  later  the  conception  that  many  cases  were 
curable  received  more  general  approval,  and  now  we  have  arrived  at 
the  conclusion  that  the  dreaded  tuberculosis  is  a  disease  of  relatively 
small  danger,  since  it  kills  only  about  seven  to  ten  per  cent  of  all  those 
infected. 

This  change  in  our  c(?hception  has  not  been  brought  about  with  the 
beginning  of  a  new  therapeutic  era,  not  with  the  discovery  of  a  great 
specific  remedy  which  can  cure  the  disease  in  a  most  unexpected  man- 
ner, but  simply  by  the  different  prognostic  conclusions  based  upon  a 
greater  refinement  of  diagnostic  methods. 

x\n  analogy  to  this  may  be  found  in  some  diseases  of  trees  which 
formerly  were  recognized  only  by  the  fact  that  the  boughs  would  fall 
in  a  certain  way  just  before  the  tree  died.  Then  it  was  recognized  that 
caterpillars  had  bored  themselves  through  the  sap-ducts  of  the  tree, 
destroying  them,  and,  further,  that  also  such  trees  showed  furrows  made 
by  caterpillars,  without  having  been  killed  by  tliem.  Finally,  the  moth, 
which  produces  the  caterpillar,  and  the  eggs  were  recognized,  and  it 
was  observed  that  the  latter  were  deposited  in  almost  every  tree,  but 
that  most  of  the  trees  opposed  a  resistance  to  the  development  of  the 

•  Dr.  von  Pirquet's  article  does  not  undertake  to  review  the  subject  systematic- 
ally. Articles  dealing  with  detail  questions  relating  to  tuberculosis  in  children  and 
of  particular  interest  to  the  practitioner  will  be  found  in  other  parts  of  the  book. 
But  it  seemed  of  particular  value  at  this  moment  to  give  to  the  reader  an  entirely 
subjective  expression  on  tuberculosis  in  childhood  based  upon  Dr.  von  Pirquet's 
own  investigations.  As  such  it  is  hoped  that  this  contribution  from  our  most  recently 
acquired  American  author  will  prove  both  interesting  and  stimulating.  The  author 
wishes  to  add,  however,  that  the  views  expressed  in  this  article  are  in  many  points 
based  on  work  and  views  of  Koch,  von  Behring,  Naegeli,  Cornet,  Bang,  Bartel, 
Finkelatoin,  and  especially  F.  Hamburger.  He  apologizes  for  not  having  made  any 
references  in  the  text  to  the  work  of  others. — The  Editor. 

141 


142  INTRODUCTION 

caterpillars.  And  to-day  it  is  not  necessary  any  more  to  saw  the  tree 
to  pieces  in  order  to  discover  the  furrows  of  tlie  caterpillars  or  to  search 
for  the  eggs;  it  is  sufficient  to  recognize  in  the  minute  alterations  of 
the  hark  the  fact  that  the  moth  has  deposited  its  eggs,  and  we  need  only 
take  a  leaf,  immerse  it  in  the  poison  of  the  caterpillar,  and  demonstrate 
by  its  discoloration  whether  the  tree  is  already  infected  or  not. 

Thus  tuberculosis  was  formerly  recognized  only  in  one  of  its  ter- 
minal stages,  pulmonary  phthisis,  when  tlie  lung  was  so  far  destroyed 
that  its  excavation  produced  a  distiiktly  altered  hnding  upon  physical 
examination,  together  with  a  marked  emaciation  of  the  whole  body. 
Then  the  identity  of  this  dreaded  lung  disease,  with  many  other  chronic, 
though  not  so  unconditionally  fatal,  diseases  of  the  bones,  joints,  and  ser- 
ous cavities,  was  established.  Then  the  tubercle  bacillus  was  discovered, 
and  it  was  found  not  only  in  phthisis,  Init  also  in  the  sputum  of  per- 
sons without  emaciation,  and  no,  or  only  slight,  alterations  of  the  phys- 
ical phenomena  in  the  lungs;  it  was  even  discovered  at  the  autopsy  of 
bodies  of  people  who  had  died  from  entirely  different  diseases.  Soon 
it  became  apparent  that  the  small  caseous  foci  of  lymph  glands  which 
were  found  accidentally  in  most  autopsies  were  also  produced  by  the 
infection  with  the  tubercle  bacillus;  and,  inially,  it  was  possible  to 
demonstrate  by  the  reaction  to  tuberculin  that  almost  everyone  at  one 
time  or  other  of  life  had  been  infected,  but  that  this  infection  led  to  a 
clinical  disease,  or  even  to  death,  only  in  a  relatively  small  percentage 
of  the  cases.  Of  great  importance  was  the  discovery  that  these  infec- 
tions took  place  already  during  childhood,  so  that  at  fourteen  years 
practically  everybody  had  already  been  subjected  to  it. 

If  it  is  true  that  the  majority  of  people  are  infected  during  child- 
hood, it  must  be  concluded  that  the  most  useful  revelations  about  the 
incipient  stages  of  tuberculosis  are  to  be  expected  from  the  investiga- 
tion of  pediatricians.  The  whole  pathology  of  adults  demonstrates  only 
chronic  processes  or  reinfections  or  terminal  stages  of  the  disease,  the 
beginning  of  which  must  be  referred  to  childhood. 

And  it  is  just  this  very  first  accpiaintanceship  with  the  causative 
factor  of  the  disease  which  ])rimarily  merits  our  attention. 

Portal  of  Entrance  for  Infection. — The  first  infection  of  the  organ- 
ism takes  place  most  probably  in  the  majority  of  cases  through  tubercle 
bacilli  which  are  expectorated  with  the  sputum  of  chronically  diseased 
adults,  and  which  enter  the  lungs  of  children  with  dust  or  in  the  form 
of  "  droplets."  Here  the  bacilli  penetrate  the  mucous  membrane,  which 
does  not  yet  react  with  defensive  measures,  and  they  reach  the  regionary 
IjTnph  glands  in  the  hilus.  Here  they  multiply  according  to  the  laws 
of  their  species,  the  same  as  on  a  favorable  medium.  The  products  of 
their   excretions   stimulate  the  formation   of   antibodies ;  the   organism 


TUBERCULOSIS   IN   CHILDHOOD  143 

forms  antagonistic  substances  wliich  "  digest "'  and  remove  the  bacilli 
and  their  poisons.  The  tubercle  bacilli,  however,  are  not  as  easily  de- 
stroyed as  other  pathogenic  bacteria;  tliey  are  protected  by  a  waxy  coat 
and  remain  alive  in  places  where  larger  colonies  have  been  formed.  But 
here  they  are,  in  a  sense,  "  locked  in."'  The  cells  surrounding  them 
multiply  and  die,  around  the  focus  a  necrotic  zone  is  formed,  the  lymph 
gland  swells,  degenerates,  caseates. 

Other  Portals  of  Entrance. — Infection  through  the  lung  is  not  the 
only  possible,  but  the  most  frequent,  mode  of  entrance  of  the  tubercle 
bacillus.  It  can  also  use  other  routes,  if  the  portals  are  accidentally 
open.  Thus  the  dipiitheria  bacillus,  for  instance,  first  invades  the  ton- 
sils, but  if  it  accidentally  reaches  an  irritated  vvdvar  mucosa,  or  an 
intensely  eczematous  epidermis,  it  can  find  here  also  favorable  condi- 
tions for  a  foothold.  In  the  same  way  also  the  tubercle  bacillus  can 
be  inoculated  into  Fome  part  of  the  epidermis  or  mucosa.  Of  the  nu- 
merous tubercle  bacilli  which  are  swallowed  and  which  proceed  through 
the  intestinal  canal,  very  rarely  one  finds  a  chance  to  enter  the  mucosa 
capable  of  producing  here  a  primary  lesion.  In  practical  pediatrics  this 
route  seems  to  ])lay  a  very  insignificant  role. 

Clinical  Stages. — We  have  no  accurate  knowledge  as  to  tlie  duration 
of  the  primary  stage  of  lymphatic-gland  infection.  It  is  possible  that 
the  tubercle  bacilli  remain  a  long  time  deposited  in  the  lymph  glands, 
without  any  signs  of  multiplication  and  without  producing  local  or  gen- 
eral reaction.  But  in  analogy  with  other  infectious  diseases  and  from 
the  experiences  with  bovine  tuberculosis  it  seems  -probable  that  the  for- 
mation of  antibodies,  and  with  it  the  reactivity  of  the  organism,  begins 
with  the  second  week  after  the  infection,  and  is  increased  until  the 
primary  process  has  found  an  apparent  termination.  These  primary 
stages  have  so  far  escaped  clinical  recognition,  but  it  is  to  be  hoped 
that  they  will  become  accessible  for  our  diagnosis  through  a  further 
refinement  of  methods  of  examination.  It  is  presumable  that  the  first 
eight  to  ten  days  after  the  entrance  of  the  tubercle  bacillus  produce  no 
discernible  symptoms,  and  that  hereafter  through  seVferal  weeks  a  slight 
fever  and  general  malaise  may  be  observed. 

The  swelling  of  the  l3'niph  glands,  furthei-more,  can  be  observed 
symptomatically  only  when  producing  a  mechanical  obstacle.  The  tuber- 
culosis of  the  hilus  glands  leads  in  small  children  fretjuently  to  chronic 
dyspnea.  In  the  radiogram  we  then  find  the  enlarged  bronchial  gland, 
and  the  tuberculin  reaction  elicits  their  tuberculous  nature. 

The  enlargement  of  the  hilus  glands,  however,  is  in  most  cases  not 
so  considerable  that  it  exerts  a  pressure  on  the  trachea,  and  the  only 
sign  pointing  to  a  previous  infection  is  to  be  found  solely  in  the  pres- 
ence of  a  reaction  to  tuberculin,  in  the  ''  allergy  "  to  tuberculin. 


144  INTRODUCTION 

These  bacilli  are  only  harmless  foreign  bodies  for  the  organism  that 
has  never  previously  come  in  contact  with  tubercle  bacilli.  Here  they 
penetrate  without  hindrance  the  membranes,  and  so  does  also  the  extract 
of  such  bacilli;  the  tuberculin  is  for  such  an  organism  an  indifferent 
substance,  which  it  tolerates  in  every  form  and  quantity.  If,  however, 
this  organism  has  once  been  infected,  it  has  altered  its  reactivity  toward 
tubercle  bacilli  and  its  products;  it  has  become  allergic.  The  allergy 
(alios — changed;  ergeia — capacity  to  react)  is  apparently  based  on  the 
fact  that  the  organism  possesses  antibodies,  which  digest  the  bacillus  and 
its  jioisons.  But  the  products  of  digestion  are  not  harmless,  but  toxic 
bodies  for  the  neighboring  cells  and  tissues. 

Within  the  allergic  body  tuberculin  produces  a  quantitatively  gradu- 
ated production  of  poisons.  If  it  is  injected  subcutaneously,  fever  is 
produced;  if  dropped  on  the  conjunctiva,  conjunctivitis  is  set  up;  and 
if  inoculated  into  the  epidermis,  a  local  inflammation  follows.  In  the 
same  manner  the  allergic  body  is  no  more  indifferent  to  the  tubercle 
bacillus  itself.  The  bacillus  can  no  more  penetrate  without  hindrance 
the  mucosa  and  reach  the  lymph  glands,  but  it  produces  already  at  the 
portal  of  entrance  local  inflammatory  changes,  which  usually  heal.  If, 
however,  a  very  virulent  bacillus  resists  the  attack,  a  necrotic  process 
takes  place  at  this  point.  If  the  allergic  man,  for  example,  is  subjected 
to  a  new  infection  in  the  lung,  a  cavity  is  formed.  This  pulmonary 
form,  typical  in  the  adult  and  found  but  rarely  in  children,  is  there- 
fore most  probably  the  effect  of  a  reinfection  in  individuals  who  have 
become  allergic  through  a  primary  infection  in  childhood. 

We  will  now  return  to  the  consequences  of  the  first  infection.  In 
most  cases  during  primary  infection  of  older  children  the  tubercle  bacilli 
do  not  penetrate  beyond  the  regionary  lymph  glands,  and  with  caseation 
and  the  production  of  allergy  the  pathologic  process  is  provisionally 
terminated. 

This  primary  infection  with  a  termination  into  a  nonapparent,  non- 
perceived  tuberculosis  of  the  lymph  glands  has  this  advantage,  that  the 
organism  enjoys,  through  the  allergy  produced,  a  certain,  though  incom- 
plete, immunity  against  renewed  infection.  It  has,  however,  the  dis- 
advantage that  an  encapsulated  focus  containing  tubercle  bacilli  is  car- 
ried around  which  at  any  time  can  inundate  the  body  from  within  with 
its  pure  culture. 

Progression  of  the  Infection. — It  seems,  however,  that  a  localiza- 
tion of  the  process  by  the  described  mode  takes  place  but  rarely  in  very 
small  children.  It  seems  that  for  this  an  already  general  resistance  to 
bacteria  is  needed  by  which  the  bacilli  are  permanently  retained  in  the 
lymph  glands,  or  it  may  be  that  the  antibody  formation  takes  place  too 
late,  or  perhaps  that  especially  favorable  conditions  for  growth  are  en- 


TUBERCULOSIS  IN  CHILDHOOD  145 

countered  by  tlie  l)acteria.  At  any  rate,  here  we  find  almost  always  a 
transition  into  a  fatal  tuberculosis.  The  character  of  the  disease  is 
essentially  different  from  that  of  the  adult.  Nurslings  do  not  die  from 
the  poisoning,  nor  from  a  far-advanced  local  disease,  nor  from  the  slow 
"  carcinomatous  "  disintegration  of  their  lungs,  nor  from  secondary  me- 
chanical obstructions,  but  from  the  general  lymphatic  infection.  It  may 
be  said  they  are  overwhelmed  by  tuberculous  formations  through  the 
lymphatic  route.  Death  in  this  case  takes  place  either  with  a  general 
atrophy  or  by  the  breaking  through  of  tubercles  into  the  lungs  or  into 
the  venous  system,  producing  thereby  a  tuberculous  bronchopneumonia 
or  a  miliary  final  stage. 

With  this  we  reach  the  second  cause  of  the  general  tuberculous  dis- 
ease— the  mechanical  breaking  through  of  the  lymphatic  system,  an  inci- 
dent which  can  happen  throughout  the  whole  period  of  childhood.  The 
caseous  focus  in  the  bronchial  lymph  gland  corrodes  the  wall  of  a  vein, 
the  )»acteria  enter  the  general  circulation,  producing  a  dissemination, 
the  clinical  importance  of  which  is  dependent  on  their  number  and  the 
region  where  the  bacilli  are  deposited.  It  is,  however,  entirely  imma- 
terial whether  the  primary  focus  in  the  lymph  glands  was  of  consider- 
able size  or  whether  it  produced  clinical  symptoms.  An  exceedingly 
small  focus  containing  only  a  thousand  bacilli  can  give  origin  to  a  dis- 
semination throughout  the  body,  provided  they  are  evenly  distributed 
by  the  circulating  blood.  Therefore  we  often  see  the  onset  of  most 
severe  symptoms  of  this  kind  in  children  who  previously  seemed  entirely 
healthy. 

V.lienever  the  number  of  bacteria  is  very  large,  a  general  miliary 
tuberculosis  is  produced,  which  in  children  almost  always  is  fatal 
under  the  guise  of  an  acute  hydrocephalus.  While  in  the  adults  a  pre- 
ponderance of  pulmonary  symptoms  is  observable  in  miliary  tubercu- 
losis, in  the  child  the  most  important  consequence  of  the  general  dis- 
semination is  the  increased  secretion  of  the  ependyma,  which  produces 
a  hydrocephalus  internus  and  the  characteristic  symptoms  of  tubercu- 
lous meningitis. 

At  autopsy  one  finds  in  these  cases  in  almost  every  organ  miliary 
tubercles  of  the  same  age,  which,  because  of  their  unimportant  localiza- 
tion, made  no  impression  on  the  picture  of  the  disease.  With  small 
numbers  of  disseminated  tubercle  bacilli  it  is  entirely  a  question  of  local- 
ization which  determines  whether  clinical  symptoms  will  at  all  apj)ear, 
or  whether  it  comes  to  a  fatal  termination.  During  the  past  years  we 
have  become  acquainted  with  the  tuberculides,  which  apparently  also 
represent  a  miliary  dissemination,  which  when  only  attacking  the  skin 
would  be  borne  without  consequences.  At  autopsy  one  finds,  how- 
ever,   often    aside    from    fresh    miliary    tubercles,    older    foci    in    the 


146  INTRODUCTION 

s|)l(?en  and  kidneys,  wliicli  orij^inatc  from  a  previous  insignificant  dis- 
semination. 

It  is  very  likely  that  the  foci  which  are  developed  in  the  hones,  espe- 
cially in  the  phalanges,  in  the  vertebral  column,  etc.,  originally  were 
produced  by  a  miliary  dissemination,  of  which  only  a  few  germs  found 
favorable  conditions  for  growth. 

We  do  not  know  what  constitutes  these  favorable  conditions.  It  is 
easily  ])ossible  that  bacterial  invasions  starting  from  tuberculous  foci 
ai"e  no  rare  events,  but  that  a  vigorous  organism  destroys  the  germs 
before  they  are  able  to  form  new  colonies.  It  is  quite  certain,  however, 
that  some  definite  conditions  exist  under  which  the  tuberculous  dissem- 
ination becomes  especially  liarniful. 

Anergy. — In  this  direction  the  influence  of  measles  is  best  known. 
In  children  with  latent  tuberculosis  or  with  a  manifest,  localized  tuber- 
culosis, we  observe  frequently  during  the  course  of  measles  a  renewed 
dissemination,  ending  quite  often  fatally  as  miliary  tuberculosis  or  lead- 
ing to  the  formation  of  fresh  foci  in  the  slia})e  of  skin  tuberculides, 
scrofulous  manifestations,  and  local izati(ms  in  lungs  or  bones.  It  has 
been  found  recently  that  no  tuberculous  child  reacts  to  tuberculin  during 
a  definite  period  of  the  measles  process.  If  one  makes  daily  tul)erculin 
tests  in  children  who,  because  of  their  localized  glandular  tuberculosis, 
are  allergic,  one  finds  a  complete  disappearance  of  reactivity  with  the 
beginning  of  the  exanthem,  and  its  reappearance  again  only  after  about 
one  week.  During  this  one  week  the  organism  is,  therefore,  "  anergic  " 
— i.  e.,  nonreacting.  It  may  be  supposed  that  the  measles  process  occu- 
pies the  antibodies  which  are  needed  for  the  repulsion  of  the  tubercle 
bacilli  i)resent  in  tlie  body.  During  this  unprotected  period  the  tubercle 
bacilli  can  grow  tbroiigii  the  necrotic  protective  wall  of  a  caseous  gland, 
or  sec(m(hirv  diseases  can  also  occur,  because  now  the  circulating  tuber- 
cle bacilli  can  find  favorable  conditions  in  the  tissues,  where  at  other 
times  they  would  have  been  killed.  Similar  conditions  are  not  found 
in  the  other  cliildren's  diseases,  as  scarlatina  and  diphtheria,  but  probably 
during  the  course  of  several  other  diseases  wiiich  are  known  to  be  par- 
ticularly apt  to  prepare  the  field  for  tuberculosis,  as,  for  instance,  in- 
fluenza. And  it  seems  to  me  also  quite  likely  that  the  progress  of  tuber- 
culosis in  the  adult  is  also  fi'equently  ])romoted  by  similar  temporary 
diminutions  of  resistance.  The  point  of  comparison  lies  in  the  general 
defenselessness  which  we  encounter  in  such  conditions.  Thus  the  patient 
with  measles  is  not  only  particularly  susceptible  to  tuberculosis,  but  also 
to  diphtheria,  influenza,  and  all  germs  with  which  he  accidentally  may 
come  in  contact;  and  similarly,  during  pregnancy,  not  only  does  the 
tuberculous  process  frequently  spread,  but,  for  instance,  caries  of  the 
teeth  can  also  rajudly   increase.      We  know   that  the  spread   of  tuber- 


TUBERCULOSIS   IN   CHILDHOOD  147 

culosis  in  the  adult — that  which  up  to  now  has  been  called  the  "  incipi- 
ency  of  tuberculosis,"'  as,  for  instance,  the  manifestation  of  clinical  phe- 
nomena— usually  follows  conditions  of  general  debility,  produced  during 
a  period  of  severe  physical  exertion  on  a  poor  diet.  I  should  like  to 
draw  the  analogy  between  this  whole  category  of  generalization  in  tuber- 
culosis and  the  experiences  with  measles,  which,  however,  require  more 
precise  definition. 

Scrofulosis. — A  counterpart  of  anergy  during  measles  is  the  hyper- 
ergy,  wliicli  wc  are  accustomed  to  see  in  the  scrofulous  forms  of  tuber- 
culosis. The  etiologic  identity  of  the  old  clinical  conception  of  scrofu- 
losis and  tuberculosis,  doubted  on  the  basis  of  cellular  patholog}',  has 
become  theoretically  assured  through  bacteriologic  studies  and  the  prac- 
tical exploitation  of  the  tuberculin  reaction.  We  have  here  a  form  of 
tuberculosis  particularly  frecjuent  during  childhood  and  characterized 
by  multiple  tuberculous  foci,  with  abnormally  increased  reactivity. 

Does  this  hyperergy,  this  exaggerated  reactivity,  indicate  effective 
protective  measures,  or  is  it  the  expression  of  a  certain  anomalous  for- 
mation of  antibodies,  or  is  it  only  a  consequence  of  a  subjective  suscep- 
tibility of  the  tissues  against  tuberculous  products? 

The  child  with  hyperergy  certainly  reacts  very  intensely  to  the  tuber- 
cle bacilli  disseminated  in  its  organs,  and  at  every  point  of  deposition 
within  the  body  extensive  necrotic  changes  are  produced,  and  where  the 
skin  or  mucosa  comes  in  contact  with  tuberculous  products  intense  super- 
ficial irritations  take  place. 

The  type  of  scrofulosis  is  determined  by  the  multiple  swellings  of  the 
lymph  glands.  To  this  are  added  the  swelling  of  the  nose,  the  chronic 
eczema  at  its  entrance.  On  the  conjunctiva  there  form  phlyctena,  for- 
mations which  can  also  be  produced  through  instillation  of  tuberculin, 
and  resemble  very  much  the  efflorescences  produced  by  rubljing  tuber- 
culin into  the  skin,  and  also  to  those  seen  surrounding  the  intensely 
inflamed  cutaneous  papule  ("scrofulous"  reaction).  If  foci  are  pres- 
ent in  the  subcutaneous  tissue,  cold  abscesses  are  formed  there,  which 
are  covered  by  a  skin  of  a  purple  discoloration;  similar  cold  abscesses 
develop  also  in  the  bones. 

Multiple  localizations  of  tuberculosis  fought  by  a  hy])erergic  consti- 
tution seem  to  allow  a  better  prognosis;  at  least  we  see  the  greater  ])art 
of  "  scrofulous  forms  "  heal  gradually,  and  at  a  later  age  period  it  seems 
that  the  previously  scrofulous  individuals  possess  a  certain  resistance 
against  pulmonary  tuberculosis.  But  with  this  it  must  not  be  inferred 
that  the  termination  of  scrofulous  forms  must  necessarily  be  favorable; 
especially  in  earliest  childhood  many  hyperergic  individuals  succund)  also. 

Prophylaxis  and  Therapy. — A  prevention  of  tuberculous  infection  is, 
absolutely  speaking,  not  possible  under  given  conditions,  because  we  can- 


148  INTRODUCTION 

not  bring  up  our  children  removed  from  all  intercourse  with  infected 
individuals  as  we  are  able  to  do  with  cattle.  The  most  important,  how- 
ever, is  to  protect  them  from  infection  during  the  first  years  of  life, 
because  the  infection  during  that  period  is  the  most  dangerous.  We 
will  have  to  look  out  that  no  one  with  open  tuberculosis  shall  be  in  the 
environment  of  the  chihl,  and  we  will  eventually  have  to  remove  it  from 
a  tuberculous  father  or  mother. 

If  we  recognize,  from  a  positive  reaction  to  tul)erculin,  that  an  infec- 
tion has  already  taken  place,  then  the  prognosis  will  depend  on  the  age 
of  tlie  patient  and  the  clinical  manifestations.  The  prognosis  has  to  be 
formed  with  great  caution  during  the  first  years  of  life.  A  positive 
tuberculin  reaction  in  older  children  has  a  serious  significance  only  when 
symptoms  of  an  affection  of  the  lung,  the  bones,  or  the  serous  mem- 
branes are  to  be  found,  or  when  there  is  emaciation,  anemia,  and  an- 
orexia. In  tliose  cases  a  general  climatic  and  dietetic  therapy  is  to  be 
recommended. 


CHAPTER   I 

SYMPTOMATOLOGY   OF    PULMONAEY  TUBERCULOSIS 
By  CHARLES  L.   MINOR 

INTRODUCTION 

When  we  take  up  the  study  of  the  clinical  manifestations  of  pul- 
monary tuberculosis  as  revealed  by  its  various  symptoms  and  signs,  and 
try  to  separate  its  varieties  into  distinct  and  sharpl}^  differentiated  types 
and  to  correlate  these  with  certain  fixed  pathological  conditions,  we  find 
the  task  a  very  difficult  one,  and  a  reference  to  the  different  authors 
who  have  written  on  the  disease  shows  numerous  attempts  in  this  direc- 
tion but  no  uniformly  accepted  results.  The  reasons  for  this  lack  of 
uniformity  are  obvious;  from  the  first  early  evidences  of  the  disease 
to  those  of  the  most  advanced  trouble,  pulmonary  tuberculosis  shows  a 
marked  polymorphism  and,  more  especially,  such  a  com])ination  in  one 
and  the  same  case  of  various  conditions,  both  clinical  and  pathological, 
as  to  render  a  very  sharp  distinction  lictween  types  impossible. 

The  well-recognized  fact  that  one  form  of  the  disease  may  change 
into  another,  chronic  cases  either  changing  their  type  or  becoming  acute, 
acute  cases  sometimes  becoming  chronic,  makes  it  difficult  to  draw  a 
line  where  one  type  ceases  and  another  begins. 

Again,  it  is  known  that  there  can  exist  in  the  diseased  lung,  at  one 
and  the  same  time,  areas  of  different  kinds  of  pathological  condition 
— fibrosis,  ulceration,  acute  l)ronchopneumonia,  miliary  tuberculosis, 
etc.  In  view  of  these  facts  it  is  evident  that  any  attempt  at  a  close 
correlation  of  pathological  conditions  Avith  clinical  manifestations  is 
doomed  to  failure,  and  that  while  for  practical  purposes  it  is  necessary 
and  desirable  clinically  to  distinguish  different  types  of  pulmonary  tuber- 
culosis, the  dividing  line  between  different  forms  must  not  be  too  sharply 
drawn,  nor  must  we  try  to  fit  our  cases  too  closely  into  these  more  or 
less  arbitrary  frames. 

The  til  pes  of  the  disease  generally  recognized  are,  in  their  most  simple 
statement,  chronic  phthisis,  acute  phthisis,  and  acute  miliary  tuber- 
culosis. Many  subdivisions  of  these  main  heads  have  been  suggested, 
some  based  on  etiological,  some  on  pathological,  and  some  on  symptom- 

149 


150  SYMPTOMATOLOGY   OF    PrL.MONARY   TIBERCILOSIS     " 

atic  grounds,  but  loo  great  a  minuteness  has  no  practical  value  and  can 
onh'  lead  to  confusion,  and  it  is  better,  while  recognizing  the  different 
ways  in  which  the  chief  types  may  be  modified,  to  multiply  divisions 
as  little  as  possible. 

Chronic  Phthisis. — The  cases  of  this  type  form  the  large  majority 
of  those  seen,  and  for  all  practical  pur))oses  are  the  only  ones  in  which 
therapeutic  etforts  are  of  any  use.  Aside  from  Ibose  rare  cases  which 
begin  as  acute  phthisis,  or  even  sometimes  acute  miliary  tuberculosis, 
and  later,  by  some  happy  chance  which  we  cannot  ascribe  to  our  own 
skill,  become  chronic,  chronic  cases  may  be  said  to  begin  in  one  of  two 
ways,  as  was  pointed  out  by  Ruehle.  Either  in  the  beginning  there  is 
a  gradual  and  progressive  loss  of  vitality  and  nourishment  not  typical 
of  any  special  disease  and  frequently  mistaken  for  neurasthenia,  dys- 
pepsia, or  anemia,  this  being  followed  after  a  longer  or  shorter  period 
by  more  distinct  symptoms  of  the  disease,  such  as  cough,  expectora- 
tion, fever,  etc.,  or  else,  in  the  midst  of  good  health  the  patient  develops 
symptoms  which  are  at  least  suggestive  of  phthisis,  although  they  are 
too  often  ascribed  to  l)ronchitis,  grip,  malaria,  etc.,  and  it  is  only  after 
these  have  lasted  for  some  time  that  the  decline  of  strength,  emaciation, 
etc.,  appear,  and  the  picture  becomes  so  distinct  as  to  be  no  longer 
mistakable. 

The  latter  beginning  is  the  more  common,  but  the  former  is  more 
frequently  the  caiise  of  diagnostic  errors,  and  it  cannot  be  too  insist- 
ently noted  that  every  patient  complaining  of  loss  of  vitality,  nourish- 
ment, color,  etc.,  which  cannot  be  satisfactorily  and  clearly  accounted 
for,  should  be  regarded  as  possibly  tul)erculous  and  carefully  examined 
for  signs  of  the  disease.  These  patients  are  below  par,  feel  poorly  and 
run  down,  and  there  is  undue  languor  and  weariness — two  very  early 
symptoms.  The  patient  lacks  his  usual  energy  and  snap,  tires  out 
quickly,  and  is  not  refreshed  by  rest  or  sleep.  These  are  the  cases  which 
are  supposed  to  be  neurasthenic,  while  others,  beginning  with  anorexia 
and  indigestion,  are  called  chronic  dyspepsia;  or,  if  the  patient  becomes 
unduly  pale  with  tachycardia,  hemic  murmurs,  etc.,  he  is  treated  by 
hematinics.  Sooner  or  later,  however,  definite  symptoms  appear;  a 
slight  cough,  dry  at  first,  a  little  fever,  often  unnoticed  by  the  patient, 
an  occasional  sweat,  or  perhaps  fortunately,  a  slight  hemoptysis. 

When  the  case  begins  with  definite  symptoms,  the  most  usual  is  a 
cough,  ascribed  to  "  catching  cold,"  or  a  definite  acute  cold  resembling 
l)ronchitis  or  grij),  or  at  times  an  attack  of  what  looks  very  much  like 
mild  typhoid.  The  "  cold "  is  obstinate  and  will  not  bo  cured,  the 
"  grip  "  or  "  typhoid  "  does  not  convalesce  ])roperly,  a  cough  with  ex- 
pectoration persisting  or  developing,  though  this  at  first  tends  to  dis- 
appear with  warmer  weather,  only  to  return   in  the  fall,   some  cases 


IXTKODICTIOX  151 

having  these  siniiimr  iiiiielioratious  for  a  number  of  year?  before  a  diag- 
nosis is  made.  The  fever  begins  to  manifest  itself  actively  at  intervals, 
the  expectoration  increases  in  amount  and  becomes  more  yellow  and 
thick,  with  possibly  some  blood-streaking  or  a  small  hemorrhage.  In 
some  fortunate  cases  hemoptysis  is  the  first  symptom,  coming  on  in 
llio  midst  of  good  health,  either  without  discoverable  cause  or  after 
overexertion.  A  sudden  irritative  cough  develops,  followed  Itv  a  hoi 
feeling  in  the  chest,  and  a  mouthful  of  bright  blood  comes  up.  As  is 
noted  elsewhere  under  "  hemorrhage,"  such  1)1  ood  spittings  are  with  such 
few  exceptions  tuberculous  in  origin,  that  onli/  the  very  strongest  evi- 
dence to  the  contrary  should  justify  us  in  dismissing  the  diagnosis  of 
tuberculosis  after  such  an  hemoptysis,  even  if  symptoms  and  signs  are 
absent,  for  the  history  of  these  cases  teaches  that  practically  all  of  them 
sooner  or  later  develop  evident  symptoms  of  the  disease,  and  it  is  far 
better  to  treat  them  all  as  tuberculous,  even  if  the  case  is  prevented  from 
ever  reaching  the  stage  of  symptoms,  rather  than  to  calm  their  fears 
by  as.suring  them  it  was  ju.st  a  "  broken  vessel."  At  this  point  I  would 
note  that  a  certain  number  of  cases  are  latent  or  abortive,  though  they 
need  not  be  made  into  a  special  class  by  themselves;  the  initial  symp- 
toms which  are  often  not  recognized  at  all,  slowly  disappearing  either 
before  or  after  a  positive  diagnosis  can  be  made.  The  cough  ceases, 
the  weight  returns  to  normal,  and  the  process  is  either  arrested  perma- 
nently— these  cases  being  those  in  which  autopsy  reveals  old  scars  in 
apices — or  for  many  years,  to  break  out  again  during  some  period  of 
depressed  vitality.  The  histories  of  cases  of  tuberculosis  very  frequently 
reveal  indications  of  one  or  more  past  abortive  attacks  of  this  sort. 

Usually,  however,  the  course  of  chronic  cases,  whether  it  be  of  the 
commoner  ulcerative  form  or  of  the  more  favorable  fibroid  form,  tends 
to  be  slowly  progressive,  interrupted  by  longer  or  shorter  intervals  of 
remission,  but  never  by  a  complete  cessation  of  the  symptoms.  The 
temperature,  which  is  at  first  absent  for  considerable  periods,  becomes 
more  persistent  and  higher,  the  nourishment  slowly  decreases,  and  each 
new  exacerbation  leaves  a  larger  area  involved.  Signs  of  moisture 
appear^  a  very  slight  hectic  flush  shows  itself  in  the  cheek,  and  the 
cough  becomes  deeper  and  looser.  The  expectoration  is  now  abundant 
and  takes  on  the  characters  noted  under  "  expectoration."'  The  fever 
becomes  more  and  more  persistent  and  obstinate  and  finally  hectic. 
Emaciation  advances  to  a  pitiful  extent,  the  skin  in  some  cases  being 
tensely  drawn  over  the  bony  prominences,  and  tiie  feverisldy  I)right  eyes 
looking  at  us  for  help  from  the  bottom  of  deep  pits. 

The  end  is  usually  by  exhaustion,  and  is  generally  remarkably  easy 
and  ])eaceful,  l)ut  if  diarrhea,  laryngeal  ulceration,  or  meningitis  occur 
it  can  be  extremely  painful  and  terrible,  or  where  excavation  is  markeC 


152    SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

may  be  brought  about  by  a  single  large  hemorrhage  which  is  either  in- 
stantly fatal  or  kills  through  a  rapid,  acute  dissemination  or  pneumonia. 

Where  the  patient's  vitality  is  poor,  either  hereditarily  or  as  the 
result  of  unwise  living,  or  where  the  build  is  congenitally  bad,  the  course 
is  naturally  apt  to  be  severe  and  the  outcome  bad.  On  the  other  hand, 
in  the  wiry,  with  good  resisting  powers,  or  in  those  with  a  gouty  or 
rheumatic  tendency,  the  disease  usually  has  a  favorable  course,  with  a 
marked  tendency  to  the  deposit  of  fibroid  tissue  around  the  lesions  in 
the  lungs  and  with  less  active  symptoms.  Andrew  Clark,  in  England, 
was  the  first  to  describe  filjroid  phthisis  as  a  separate  type,  and  Soko- 
lowski,  in  Poland,  has  given  it  special  study. 

In  this  type,  if  we  admit  it  as  such,  the  whole  course  is  much  less 
active  and  the  duration  long  drawn  out.  The  fever  is  often  absent  and 
sweats  unusual,  but,  in  its  later  stages,  hemoptysis  common.  As  a  result 
of  the  shrinkage  of  the  fibroid  tissue  there  is  progressive  distortion  of 
the  chest,  as  well  as  the  formation  of  bronchiectases,  with  paroxysmal 
cough.  Dyspnea  is  also  very  marked.  This  form  is  apt  to  occur  in 
patients  after  forty  and  has  a  chronic  and  tedious  course.  AVhere  the 
course  is  progressive,  large  inactive  cavities  slowly  form  ;  l)iit,  owing  to 
the  location  of  tlie  cavities  in  the  deeper  portions  of  tbe  lungs,  the  pliys- 
ical  signs  are  indefinite.     Marked  dislocation  of  the  heart  is  also  seen. 

Such  typically  fibroid  cases,  while  slow  in  tlieir  course,  are  usually 
fatal  in  their  termination,  and  are  not  to  be  confounded  with  cases  in 
which,  as  is  necessary  in  tuberculosis,  the  healing  is  brought  about 
through  fibroid  encapsulation,  but  in  which  the  fibrosis  is  not  so  gen- 
erally marked  as  in  the  cases  described. 

Some  fibrosis  is  present  in  every  case  of  tuberculosis,  as  well  as  some 
ulceration ;  if  the  former  is  very  marked,  the  course  is  slow  and  the 
outlook  more  favorable;  if  the  latter  predominate,  the  contrary  is  the 
case;  but  it  is  not  always  possible  to  draw  any  sliarp  line,  the  majority 
of  cases  showing  a  combination  of  both  processes. 

The  commencement  gives  no  reliable  clew  to  the  future  course  of 
the  case,  for  a  severe  active  beginning  may  be  followed  by  a  favorable 
course  and  cure,  and  vice  versa ;  though  usually  a  gradual  onset  speaks 
for  a  mild  infection  and  good  powers  of  resistance. 

Some  cases,  with  very  slight  improvement  in  the  conditions  of  their 
life,  have  such  excellent  recuperative  power  as  to  throw  off  the  trouble 
quickly;  others  demand  the  cessation  of  all  work,  the  best  of  conditions, 
and  the  most  favorable  climate  if  they  are  to  pull  through  at  all ;  while 
yet  others,  from  the  first,  show  no  powers  of  resistance  to  the  advance 
of  the  disease,  despite  the  very  best  of  opportunities,  and  run  a  steadily 
downward  course.  The  duration  in  earlier  days,  when  a  diagnosis  could 
not  be  made  so  easily  and  when  treatment  was  less  effectual,  was  placed 


INTRODUCTION  153 

at  two  to  three  years,  but  the  average  is  now  more  justly  stated  at  about 
ten  years,  with  variations  all  the  way  i'lom  one  year  to  twenty  or  thirty 
or  even  more  years. 

When  improvement  occurs  it  is  usually  very  gradual,  though  cases 
removed  to  a  favorable  climate  and  under  the  best  of  conditions  will 
often  recover  quite  rapidly.  On  the  whole,  it  is  fair  to  say  that  "  appar- 
ent cure  "  demands  from  six  months  to  three  years,  from  one  year  to 
eighteen  months  being  the  average,  and  that  such  a  case  must  hold  its 
own  in  every  way  for  two  to  three  years  before  it  can  be  called  "  cured." 

The  temperature  is  usually  one  of  the  first  symptoms  to  show  im- 
provement, and  the  cough  the  last.  Under  outdoor  treatment  the 
sweats  cease  very  quickly,  expectoration  becomes  much  whiter  and,  at 
first,  more  almndant,  later  lessening,  and  finally  disappearing,  usually  a 
long  time  before  the  cough.  Appetite,  unless  there  be  a  bad  dyspepsia, 
returns  soon  in  favorable  cases.  Weight  begins  to  increase  even  in  sum- 
mer time.  Normal  energy  and  strength  reappear,  and  long  before  the 
cough  disappears  the  jiatient  looks  and  feels  as  well  as  or  better  than  ever 
in  his  life.  In  favorable  incipient  cases  the  "apparently  cured"  case 
may  anticipate  the  resumption  of  his  occupation  in  his  old  home  if  his 
surroundings  are  of  the  best  and  his  life  of  the  wisest,  but,  in  propor- 
tion as  the  recognition  of  the  disease  is  delayed,  a  retention  of  the 
restored  health  will  denumd  more  and  more  favorable  conditions  of  cli- 
mate, surroundings,  and  occupation,  and  in  the  more  advanced  cases  the 
patient  should  be  well  content  if,  by  giving  up  all  work  and  living  in 
the  very  best  possible  climate,  he  can  live  as  an  arrested  case. 

Acute  Phthisis. — Acute  phthisis  arises  either  as  the  result  of  the 
mobilization  of  the  bacilli  from  some  unsuspected  focus,  probably  most 
commonly  a  bronchial  lymph  gland,  or  else  develops  in  the  course  of  a 
chronic  phthisis.  Two  types  are  usually  distinguished — the  acute  caseous 
or  tuberculous  pneumonia,  which  is  lobar  in  type,  and  the  acute  dis- 
seminated tuberculosis  or  bronchopneumonic  phthisis,  lobular  in  type. 
Both  are  of  short  course,  three  weeks  to  six  months,  and  of  almost  uni- 
formly fatal  outcome.  It  should  be  remembered  that  the  clinical  pic- 
ture may  often  be  indistinct,  running  in  the  borderland  between  the 
iiiihl,  acute  type,  and  the  more  severe  chronic  one.  Many  chronic  cases 
have  ])eriods  when  more  or  less  extensive  areas  of  acute  phthisis  exist 
in  the  lung,  which  may  or  may  not  go  on  to  pronounced  acuteness,  and 
only  the  relatively  small  extent  of  these  acute  areas  can  differentiate 
these  cases  from  acute  ones.  In  fact,  as  several  authors  have  pointed 
out,  the  symptoms  and  signs  of  the  two  types  differ  only  in  their  inten- 
sity and  ill  tlic  lime  in  whicli  they  take  to  develop,  the  symptoms  of  an 
acute  case  being  only  those  of  a  chronic  one  raised  to  a  much  higher 
power  and  concentrated  in  a  much  shorter  time. 


154  SYMPTOMATOLOGY   OF   PULMONARY  TUBERCULOSIS 

Of  the  two  types  of  acaite  plithi(-is,  acute  caseous  ])neuni(niia  is  most 
apt  to  rise  de  novo  in  au  apparently  well  i)erson— often  in  the  athletic; 
the  other  form,  which  is  more  chronic,  usually  originating  in  a  patient 
who  is  already  frankly  tuberculous. 

Acute  caseous  imeumonia  appears  usually  under  the  guise  of  ordi- 
nary lobar  pneumonia,  with  a  chill  and  sudden  rise  of  temperature, 
though  the  pain  in  the  side  is  apt  to  be  absent.  The  sputum  is  gen- 
erally rusty,  and  since  bacilli  are  not  found  in  it,  it  cannot  be  distin- 
guished from  real  pneumonia,  unless,  as  is  at  times  the  case,  it  follows 
a  sudden  hemoptysis,  such  pneumonias  always  being  presumptively 
tuberculous. 

For  the  first  few  days  the  course  is  that  of  an  ordinary  pneumonia, 
the  fever  being  continuous  and  typical,  and  while  there  is  undue  pros- 
tration it  is  not  sufficiently  marked  to  be  diagnostic.  In  the  second 
week,  however,  our  susj)icions  will  be  awakened.  Instead  of  a  crisis 
occurring,  the  fever  becomes  irregular,  and  later  may  be  hectic,  with 
chills  and  sweats,  and  resolution  does  not  aj)pear.  The  great  dyspnea 
is  suspicious,  as  is  the  unusual  ])allor  and  especially  the  cyanosis,  while 
the  sputum  tends  to  become  profuse  and  olive-green  in  color,  and  after 
two  or  three  weeks  bacilli  may  be  discovered,  althougii  deatii  may  occur 
before  they  appear.  AVlien  the  course  is  very  acute,  the  end  comes  ))y 
exhaustion  in  three  to  six  weeks;  l)ut  the  course  may  be  subacute,  and 
then  the  consolidated  areas  have  time  to  show  signs  of  softening,  which 
may  go  on  to  cavity  formation;  while  new  extensions  appear  in  other 
portions  of  the  lungs,  first  manifested  by  fine,  dry  crackles,  changing 
quite  rapidly  to  fine  and  medium  moist  rPdes,  with  which  small  areas 
of  dullness  will  soon  be  associated.  In  one  case  of  mine,  where  the 
initial  trouble  was  a  massive  consolidation  of  the  upper  left  lobe,  later 
extending  to  the  lower,  small  patches  of  bronchopneumonia  developed 
in  the  front  and  l)ack  of  the  right  lung,  while  the  left  upper  lobe  was 
going  on  to  complete  excavation.  Strange  to  say,  despite  the  marked 
exhaustion,  nourishment  remains  very  good  for  some  time  and  the  appe- 
tite is  quite  fair.  Where  the  course  is  prolonged,  as  it  may  be  for  from 
two  to  six  months,  the  end,  if  not  by  exhaustion,  is  apt  to  be  by 
meningitis. 

The  second  and  more  ordinary  form  of  acute  tuberculosis  is  the 
acute  ulcerative  lohiilar  phthisis  of  the  French,  or  the  acute  dissemi- 
nated tuherculosis  of  Fraenkel,  ])opularly  and  graphically  called  "gal- 
loping consuni])tion."'  As  the  nanu^  indicates,  it  is  bronchopneunionic 
in  form  and  very  ra]iid  in  course,  with  great  destruction  of  tissue,  if 
life  bo  sufficiently  prolonged.  It  is  very  common  in  cliildliood  and  ado- 
lescence, as  a  result  of  measles  and  pertussis,  as  also  in  the  eoui'se  of 
exhausting   maladies,   such    as   grip    and    ty])hoid,    and    more    especially 


INTRODUCriON  155 

diabetes,  while  the  tuberculosis  which  develops  after  pregnancy  and  runs 
a  rapidly  fatal  course  is  of  this  form.  It  can  also  develop  in  the  course 
of  a  chronic  tuberculosis  as  a  result  of  a  large  hemorrhage  (Baumler), 
these  being  the  acute  disseminations  seen  sometimes  after  hemoptysis, 
or  it  can  arise  through  the  aspiration  of  the  contents  of  a  cavity.  Fraen- 
kel  divides  it  into  three  varieties,  the  hemorrhagic,  the  peribronchitic, 
and  the  disseminated  ulcerous,  but  such  minuteness  of  division  I  do 
not  believe  desirable.  The  rapid  destruction  characteristic  of  this  type 
has  by  some  been  ascribed  to  mixed  infection. 

The  beginning  in  patients  not  apparently  tuberculous  can  be  very 
sudden,  resembling  an  attack  of  grip,  with  chilliness,  aching  of  the 
joints,  fever,  cough,  and  expectoration;  while  in  the  tuberculous  it  first 
appears  under  the  guise  of  an  exacerbation  of  the  trouble  with  increase 
of  the  already  existing  symptoms.  In  either  case  the  development  is 
rapid,  the  color  fades  away  quickly,  the  pulse  becomes  fast,  and  the 
expectoration,  whicli  is  at  first  mucoid  and  scanty,  and  may  be  tempo- 
rarily rusty,  as  separate  areas  of  bronchopneumonia  form,  finally  becomes 
purulent  and  abundant  and  swarms  with  bacilli;  though  in  cases  arising 
in  the  apparenth'^  healthy,  germs  may  not  appear  for  some  time.  The 
cough  is  severe  and  fatiguing,  and  dyspnea  and  cyanosis  marked,  the 
former  being  out  of  all  jjroportion  to  the  physical  signs.  The  fever  is 
high  and  intermits  once  or  more  a  day,  with  chills  and  profuse  sweats. 
The  physical  signs  are  those  of  bronchopneumonia,  with  fine  and  medium 
moist  rales,  and  though  widely  disseminated  they  show  a  tendency  to 
localize  themselves  (Grancher).  Impaired  resonance  soon  appears,  and 
later  signs  of  excavation,  the  lungs  seeming  to  melt  away  from  day  to 
day  under  the  virulence  of  the  process.  Emaciation  may  be  very  rapid 
and  is  more  common  than  in  the  lobar  form,  but,  as  in  that  form,  it  is 
not  always  present.  Usually  the  course  is  from  two  to  six  months  and 
the  end  comes  by  exhaustion,  hemorrhage,  meningitis,  or  the  develop- 
ment of  acute  miliary  tuberculosis.  In  some  cases  the  rapidity  of  the 
fatal  course  is  extreme — a  case  in  my  practice  dying  in  three  weeks 
from  the  date  of  an  anesthesia  which  brought  her  chronic  tuberculosis 
to  activity.  Some  cases,  desperate  as  they  are,  sui'prise  us  by  a  gradual 
lessening  of  the  intensity  of  the  process,  and  again  become  chronic  for 
a  time,  but  a  real  recovery  from  this  type  of  the  disease  must  be  ex- 
tremely rare. 

Acute  Miliary  Tuberculosis. — Acute  miliary  tul)erculosis  is  not  so 
much  a  pulmonary  as  a  constitutional  disease,  but,  save  in  its  menin- 
geal form,  which  need  not  be  dwelt  on  here,  it  has  pulmonary  mani- 
festations of  sufficient  importance  to  demand  a  description.  It  appears 
under  three  forms — typhoid,  bronchopneumonic,  and  nu'ningeal. 

The  typhoid  form  is  the  result  of  a  general  systemic  infection,  hence 


156  SYMPTOMATOLOGY   OF    PULMONARY   TUBERCULOSIS 

the  Frencli  name  of  septicetnie  hacillair-e  or  typho-hacillose.  Like  all 
such  infections,  it  usually  has  a  prodromal  stage  of  from  one  to  three 
weeks,  during  which  the  patient  is  languid,  has  dull  headache,  anorexia, 
and  a  slight,  generally  overlooked  fever.  The  active  stage  begins  with 
high  fever,  which  at  first  is  continuous  and  not  to  be  distinguished  from 
typhoid,  though  later  it  is  irregular,  with  marked  remissions,  or  even 
intermissions,  of  one  or  two  days. 

The  general  resemblance  of  tlie  symptoms  to  typhoid  is  so  close  that 
the  best  diagnosticians  have  often  been  deceived,  and  in  many  cases 
only  an  autopsy  can  make  the  distinction.  The  prostration  is  greater 
than  is  usual  in  typlioid  and  the  headache  severe.  Anorexia  is  the  rule, 
as  is  consti])ation,  but  diarrhea  may  be  i)resent,  and,  to  add  to  the  diffi- 
culty, rose  spots  can  be  found  in  some  cases  and  the  spleen  and  liver 
are  enlarged.  The  pulse  is  Aveak  and  unduly  fast  (130-150),  unless 
meningeal  involvement  exists,  and  there  is  hyperesthesia  of  the  skin  and 
underlying  muscles  (Empis),  especially  of  the  abdomen  and  chest.  The 
cough  is  not  ditferent  from  that  seen  in  the  beginning  of  typhoid,  and 
the  scanty  sputum  is  aerated,  mucoid,  and  shows  no  bacilli,  and  the 
physical  signs  are  at  this  time  only  a  few  sibilant  rales  here  and  there, 
later  replaced  by  fine  moist  rales,  fixed  in  location,  but  appearing  and 
disappearing.  Faint  frictions,  due  to  subpleural  tubercle  (Jlirgensen), 
can  also  at  times  be  found.  Percussion  is  negative.  In  suspicious  cases 
the  lungs  must  be  watched  closely  if  we  are  to  discover  the  ofttimes 
very  slight  auscultatory  changes.  As  in  all  acute  cases,  the  two  most 
typical  symptoms  are  the  undue  dyspnea  and  the  cyanosis.  Tlie  for- 
mer appears  early  and  continually  increases.  The  latter  is  especially 
noticeable  in  the  finger  nails  and  is,  I  believe,  a  very  reliable  symptom. 
Unlike  typhoid,  the  skin,  where  not  cyanotic,  is  unduly  pale.  If  the 
meninges  are  not  involved  the  nervous  symptoms  are  not  very  marked, 
being  like  those  of  typhoid  in  its  early  stages — i.  e.,  apathy,  headache, 
and  slight  wandering.  In  the  second  week  the  meningeal  involvement 
is  usually  pronounced  and  severe  delirium  ajipears.  The  wasting,  espe- 
cially of  the  chest  and  muscles,  is  marked,  as  is  the  pallor,  and  the 
fever  now  becomes  irregular  and  is  accompanied  by  sweats.  The  course 
is  usually  from  tliree  to  fofh-  weeks,  but  can  be  prolonged  to  many  weeks, 
and  Grancher  believes  that  there  can  be  an  attenuated  form  running 
on  for  a  long  time. 

The  difficulties  of  diagnosis  are  such  that  prol)ably  the  majority  of 
cases  are  ascrijjcd  to  typhoid,  and,  indeed,  the  attacks  of  "typhoid 
fever  "  in  the  beginning  of  chronic  tuberculosis,  of  wliich  one  is  often 
told  in  histories,  Avere  probably,  in  a  certain  proportion  of  the  cases, 
acute  tuberculosis  which  later  became  chronic;  an  ending,  the  possi- 
bility of  which,  while  difficult  to  prove,  can  scarcely  be  doubted.     The 


INTRODUCTION  157 

Widal  reaction,  if  positive,  can  exclude  tul^erculogis  if  we  are  sure  the 
patient  has  not  had  typhoid  in  recent  years,  l)ut  its  al)sence,  nnfortu- 
nately,  does  not  justify  us  in  considering  the  case  tuherculous. 

The  demonstration  of  tubercles  in  the  choroid  (Litten)  which  can 
produce  dimness  of  vision  (Graefe)  is,  of  course,  diagnostic,  as  is  the 
discovery  of  tubercle  bacilli  in  the  blood,  if  it  can  be  made;  and  now 
that  the  advance  of  bacteriologic  technic  promises  to  render  the  dis- 
covery of  the  bacillus  of  tuberculosis  and  of  typhoid  in  the  Ijlood  more 
easy,  it  is  justifiable  to  hope  that  we  will  have  a  relialde  means  of  dif- 
ferentiating these  two  diseases. 

When  acute  miliary  tubeixailosis  develops,  not  apparently  de  novo, 
but  in  a  patient  suffering  from  chronic  tuberculosis,  the  diagnosis  is 
less  difficult,  and  it  need  scarcely  be  noted  that  in  douljtful  cases  the 
search  for  old  foci  nmst  be  very  thorough,  for  in  such  cases  it  is  apt 
to  be  mistaken  for  influenza.  The  temjjerature  suddenly. rises  very  high, 
with  chills,  but  the  development  of  dyspnea  and  cyanosis,  and  later  of 
meningeal  symptoms,  may  help  to  clear  up  our  doubts. 

At  times  in  acute  miliary  tuberculosis  such  enormous  numbers  of 
bacilli  enter  the  circulation  at  once  as  to  overwhelm  the  patient,  and  to 
kill  by  toxemia  before  any  histological  evidences  df  the  process  have 
had  time  to  form  (Fraenkel),  and  in  such  cases  death  occurs  in  from 
one  to  two  weeks,  with  signs  of  intense  intoxication,  combined  with 
great  dyspnea,  cyanosis,  and  tachycardia ;  but  unless  we  know  the  pre- 
vious existence  of  tuberculosis  in  the  case,  diagnosis  cannot  be  made. 
Such  a  case  in  my  practice  developed  two  days  after  a  simple  hemor- 
rhage, and  was  marked  by  influenzalike  joint  and  body  pains,  rapidly 
increasing  dyspnea,  the  respiration  toward  the  end  reaching  52  to  62, 
intense  cyanosis  and  a  tachycardia  of  144  to  160,  along  with  renal 
(anuria)    and  meningeal  symptoms,  death  occurring  in  six  days. 

The  bronchopulmonary  form  usually  begins  with  a  not  very  diffused 
bronchitis  showing  isolated  areas  of  catarrh  of  the  fine  tubes,  recognized 
by  fine  crackles  or  fine  moist  rales,  but  with  no  breath  changes,  or,  at 
most,  feeble  Ijreathing.  Percussion  changes  are  al)sent.  The  sjnitum  is 
scanty  and  glairy,  though  it  can  be  rusty.  Bacilli,  unless  an  old  chronic 
focus  be  present,  are  absent.  The  temperature  is  irregular,  the  dyspnea 
marked,  and  the  pulse  rapid.  It  is  common  in  children,  and  can  in 
them  simulate  a  simple  bronchopneumonia,  and  every  child  having  this 
disease,  when  the  resolution  is  delayed  and  dyspnea  pronounced,  should 
be  closely  watched. 

In  adults  it  is  usually  mistaken  for  grip,  and,  in  the  absence  of 
bacilli  in  the  sputum,  only  the  final  outcome  can  exclude  tuberculosis — 
as  in  a  case  in  my  practice,  where  a  primipara  with  an  old  arrested 
tuberculosis  developed  four  weeks  after  delivery,  and  after  recent  expo- 


158  SYMPTOMATOLOGY   OF   PLTLMONARY  TUBERCTtI.OSIS 

sure  to  influenza,  symptoms  typical  of  acute  miliary  tuberculosis,  fine 
crackles  in  the  lungs,  intermittent  high  fever  (105°  F.),  and  chills,  a 
rapid  pulse,  and  dyspnea,  but  no  cyanosis.  T  felt  very  sure  that  the 
pregnancy  had  mobilized  bacilli,  l)ut  the  gradual  disappearance  of  the 
signs  and  symptoms  in  four  weeks,  and  a  return  to  previous  health, 
showed  that  it  had  been  a  grippal  infection.  The  cough  is  dry  and 
hacking,  but  not  severe;  the  fever  very  irregular,  and  at  times  hectic, 
with  sweats,  etc.     The  course  is  rapid,  from  three  weeks  to  two  months. 

French  authors  have  also  pointed  out  a  modification  of  this  form, 
which  they  call  "suffocative"  {tuberculose  aigue  suffocante),  marked 
by  sudden  dyspnea  of  great  intensity,  suggesting  asthma,  weak  or  absent 
breath  sounds,  sibilant  rales,  no  expectoration,  enormous  tachycardia 
(180  to  200),  ra])id  emaciation,  and  high  fever,  death  occurring  from 
exhaustion  in  two  to  three  weeks. 

A  pleural  form  is  also  recognized,  beginning  either  suddenly  with 
effusion  and  high  fever,  or  gradually.  In  the  first  case  there  is  chill, 
fever,  and  pain;  but,  unlike  a  simple  pleurisy,  there  are  marked  toxic 
symptoms,  and  it  is  apt  to  end  suddenly  in  meningitis.  The  rapid 
course,  great  exhaustion  and  intoxication,  and  the  brain  symptoms  must 
be  relied  on  for  diagnosis.  The  fact  that  the  dyspnea  is  out  of  propor- 
tion to  the  amount  of  effusion,  and  the  undue  wasting,  may  assist  in 
the  diagnosis.     The  course  is  from  five  to  six  weeks. 

Before  turning  our  attention  to  the  individual  symptoms  and  signs 
of  pulmonary  tuberculosis,  it  need  scarcely  be  noted  that  we  must  regard 
them  as  a  whole  and  in  their  relation  to  each  other,  rather  than  indi- 
vidually, if  we  are  to  get  a  proper  impression  of  the  case,  and  that  in 
the  study  of  the  symptoms  we  should  never  forget  the  sick  individual 
as  to  whose  needs  the  symptoms  and  signs  are  our  guides. 

Both  prognostically  and  therapeutically,  symptoms  are  of  more 
value  to  the  physician  than  signs.  It  is  an  everyday  experience  that  a 
patient  can  present  quite  extensive  physical  signs  while  enjoying  rela- 
tively good  health  and  working  efficiency;  while  at  times  a  person  with 
severe  symptoms  and  who  is  in  a  serious  condition  may  present  signs 
which  surprise  us  by  their  relative  insignificance.  Therefore,  in  esti- 
mating the  chances  of  our  patients,  we  sliould  be  careful  not  to  fall 
into  the  common  error  of  basing  our  opinion  chiefly  on  the  signs,  or, 
in  the  diagnosis  of  a  case,  of  neglecting  symptoms  such  as  hemoptysis, 
chronic  cough,  languor,  etc.,  because  marked  physical  signs  oannot  be 
demonstrated. 

It  is  true  that  in  diagnosis  signs  are  of  the  greatest  value,  but  even 
here  they  can  only  be  properly  studied  in  conjunction  with  symptoms, 
and  diagnosis,  after  all,  is  only  of  value  as  it  leads  to  a  correct  prog- 
nosis and  a  rational  treatment,  and  for  these,  as  noted,  symptoms  are 


SUBJECTIVE   SYMPTOMS 


159 


tlic  (leterminiug  ractor.  Henco  \vf  cau  H'e  ihv.  gr^ai  need  of  a  very 
careful  study  <>f  the  history  and  the  current  symptoms.  In  this  con- 
iieetion  it  is  a  great  mistake  for  the  physician  to  l)elittle  or  neglect 
syin))t()ins  noted  hy  the  patient  without  first  carefully  investigating 
them.  Wliile  the  neurotic  can  develop  many  and  unimportant  symp- 
toms, it  is  not  rare  to  have  an  intelligent  patient  notify  us  of  feelings 
which  we  dismiss  as  unimportant  hut  wliich  the  later  course  of  the  case 
proves  to  have  heen  early,  and  had  they  heen  heeded  and  rightly  valued, 
very  useful  warnings  of  impending  hemorrhage,  congestion,  pleurisy,  etc. 
Hence  it  is  advisahle  to  give  careful  attention  to  all  reports  of  unusual 
sensations,  and  not  to  dismiss  them  from  consideration  too  quickly. 

Again,  in  the  course  of  a  recovering  case  of  pulmonary  tuherculosis, 
the  symptoms  disappear  at  a  time  when  physical  signs  can  still  Ik-  easily 
found,  and  since  the  former  are  the  only  evidence  the  patient  has  of 
his  sickness,  he  is  apt,  unless  he  is  unusually  carefully  trained  and 
taught,  as  soon  as  they  cease  to  trou])le  him,  to  forget  that  he  is  a  sick 
man,  thus  frequently  leading  to  imprudences  and  relapses. 

Finally,  at  the  risk  of  repetition,  let  it  he  once  more  noted  that  the 
rational  study  of  a  case  implies  a  consideration,  not  of  any  few  promi- 
nent features,  whether  from  the  history,  previous  examination,  or  clinical 
study,  hut  a  broad-minded  consideration  of  all  and  their  correlation 
into  a  complete  whole,  so  that  we  may  get  a  broad  and  clear  picture  of 
one  malady  which  we  are  called  to  treat.  Only  so  will  our  results  be 
a  credit  to  ourselves  and  of  benefit  to  our  patients. 


SUBJECTIVE   SYMPTOMS 

Fever. — Of  the  constitutional  symptoms,  fever  occupies  the  most 
important  place  from  a  diagnostic  and  prognostic  point  of  view,  and 
as  a  guide  to  treatment.     It  gives  one  of  the  earliest  evidences  of  the 


Day   4   5   6   7   8   y   10  11   IJ  13   U  15  16  17  18  19  20  21  22  23  24  25  26  27  28 


SP?-i?-::EESfe^ 


Fig.  24. — Stage  I.    Typical  Moderately  Subnormal  Temperature. 
Marked  neurasthenia.     (Case  G.  E.  B.) 


activity  of  the  bacillus,  and  while  some  have  maintained  that  simple, 
uncomplicated  tuberculosis  is  afebrile,  the  consensus  of  medical  opinion 
is  against  such  a  contention.  Tiiis  view  seems  to  be  fully  justified,  not 
only  because  of  the  well-known  effects  of  the  injection  of  the  products 


160 


SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 


of  the  bacillus  into  the  human  body,  but  also  because  of  the  elevations 
in  temperature  wliich  so  uniformly  accompany  increase  in  activity  of  the 
tuberculous  process,  and  the  falls  which  follow  each  decrease  in  activity. 


Fig.  25. — Stage  I.    Marked  Subnormal  Temperature  in  Young  Woman  of  Very 
Poor  Vitality.    Note  effect  of  moderate  amounts  of  alcohol.     (Case  B.  G.) 

Technic  of  Measurements. — Temperature  observations,  to  be  of 
value  in  the  diagnosis  of  tuberculosis  and,  although  in  a  less  degree, 
in  the  treatment,  must  be  taken  every  two  hours.  The  usual  custom  of 
taking  the  temperature  three  times  a  day,  or  only  in  the  afternoon, 
is  a  bad  one,  because  then  important  fluctuations  are  often  missed.  The 
patient  can  easily  be  taught  to  take  his  own  temperature  accurately,  and 
it  is  better  for  tbe  doctor  to  fear  a  mistake  in  diagnosis  than  to  fear 
alarming  a  nervous  patient. 


Day 


Hp^^s-aK^:£^^is||pe??:|fe^ 


Fig.  26. — Stage  II.     Slowly  Spreading  and  with  Gradually  Rising  Fever. 
Progressing  general  dissemination.     (Case  J.  C.) 

It  is  very  important  also,  in  a  disease  in  which  a  few  tenths  of  a 
degree  of  variation  in  the  temperature  have  so  much  significance,  that 
we  use  a  thermometer  of  whose  accurac}^  we  have  a  better  evidence  than 
the  certificate  of  its  maker.  Experience  has  taught  the  writer  that  a  large 
percentage  of  thermometers  sold  to  physicians  have  errors  greater  than 
three  tenths  of  a  degree.  At  the  same  time  the  temperature  curve  must 
not  be  relied  on  exclusively  to  the  neglect  of  other  important  data,  for 
not  rarely  an  unfavorable  case  has  a  very  satisfactor}^  temperature  curve. 
Harris  and  Beale  ('95)  note  that  the  individual  idiosyncrasy  must  be 
taken  into  account ;  different  people,  under  similar  conditions,  show 
very  different  febrile  reactions  to  the  same  stimulus,  and  very  wisely 
they  say :  "  The  absence  of  high  temperature  must  not  be  regarded  as 


SUBJECTIVE   SYMPTOMS 


J()l 


wholly  a  favorable  symptom,  if  other  sMiiptoms  of  active  disease  are 
present." 

The  measurements,  to  be  accurate,  must  Ix'  taken  for  a  full  tivc 
minutes,  no  matter  how  rapidly  the  thermometer  registers,  and  out- 
doors in  cold  weather  for  eight,  ten,  or  even  fifteen  minutes.  In  very 
cold  weather  the  patient  should  come  indoors  to  take  the  reading.  An 
interesting  study  of  this  subject  w^as  made  by  Bluhm  ('01),  who  showed 
the  effect  of  the  external  temperature  on  that  in  the  mouth.  She  noted 
that  in  the  case  of  a  patient  with  an  occluded  nose,  who  unconsciously 
from  time  to  time  opens  his  mouth  to  inhale  the  air,  readings  may  be 
imreliable.  She  also  found  that  the  difference  of  temperature  produced 
by  the  outdoor  cold  varied  in  different  patients,  but  that  the  effect 
could  be  lessened  by  covering  the  face. 

Some  German  writers  (notably  Walther,  of  Xordrach.  and  Pen- 
zoldt)    have  strongly  recommended   taking   the  rectal   temperature   be- 


Day      22 

23     24     23     2 

6     27     28      1 

I      3       4 

>       6       T 

8     g     10 

11      12 

13     14     15     16     17     18 

IT 

__j_- 

T 

1 

/V  — 

&^ 

M                   . 

-^    r*'    1  — 

-^  A. 

/^      A    r^       ^    >- 

98"— U 

^7         ^ 

._-z:7c- 

\    J\^    •' 

^^^ 

3,a7  szaid?^ 

I 

! 

V             ^     >r 

c  Y 

1 

4- 

±_ 

1 

Fig.  27. — St.\ge  III.     Extensive  Lesions  with  Normal  Temperature. 
Temporarily  no  activity  of  process.     (Case  Mrs.  M.) 


canse  it  is  more  reliable,  but  the  majority  of  clinicians  prefer  to  take 
the  mouth  temperature.  Such  trials  as  the  writer  has  made  of  the  rectal 
method  have  led  him  to  consider  it  unnecessary,  in  the  large  majority  of 
ca.^es,  and  this  agrees  with  the  conclusions  of  Schroder  and  Briihl  ('02), 
who  studied  the  subject  carefully.  Tf  the  temperature  is  taken  long 
enough,  the  mouth  readings,  in  my  experience,  have  generally  run  par- 
allel w'ith  those  in  the  rectum  and  axilla  ;  not  as  high  as  the  former 
i)y  about  a  half  degree,  nor  as  low  as  the  latter  by  the  same  amount. 
Ostenfeld  ('04),  who  uses  rectal  measurements,  found  70  per  cent  of  25(t 
cases  had  nearly  parallel  rectal  and  mouth  temperature  curves. 

Against  the  procedure  is  not  only  the  fact  that  the  manipulations 
are  most  disagreeable,  and  no  doctor  can  afford  to  disregard  the  sus- 
ceptibilities of  his  patients,  but,  much  more,  that  it  necessitates  tlu- 
patient's  going  to  his  room  each  time,  which,  if  two-hourly  observa- 
tions are  made,  is  extremely  inconvenient,  and  for  ordinary  use  its 
defects  are  not  outbalanced  by  sufficient  compensating  advantages. 
Braine-Hartwell  ('01),  who  is  an  enthusiastic  advocate  of  the  rectal 
method,  considers  it  essential  to  accuracy,  and  gives  temperature  curves 
showing  great  variations  between  the  mouth  and  rectum,  as  does  Saug- 
12 


162 


SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 


man.  In  the  case  of  bedridden  patients,  or  in  those  wliere  we  suspect 
a  temperature  which  the  mouth  does  not  reveal,  or  in  afebrile  cases 
in  which  exercise  has  a  bad  physical  effect  not  explained  by  the  ther- 
mometer, it  is  wise  to  use  this  method  long  enough  to  satisfy  oneself 
that  the  mouth  temperature  is  not  deceptive.  In  the  large  majority 
of  cases  mouth  readings  can  safely  be  relied  on  to  guide  us  in  the  study 
of  patients.  In  doubtful  cases  it  may  at  times  be  necessary,  as  noted, 
to  resort  to  rectal  measurements  as  a  control  of  mouth  readings,  as 
the  former  are  less  affected  by  external  influences  and  are  more  abso- 
lutely accurate.  Despite  the  advocacy  of  rectal  measurements  by  a 
few  well-known  authorities,  they  have  not  won  general  acceptance  by 
the  special  workers  in  this  field.  So  good  an  authority  as  Turban  is 
satisfied  with  mouth  readings  in  most  cases. 

Course  of  the  Fever. — While  many  attempts  have  been  made  to 
distinguish  a  temperature  curve  typical  for  tuberculosis,  such  as  exists 
for  typhoid,  the  polymorphism  of  the  disease  renders  this  impossible. 


Day       7      a       ii      lo     U 

iJ      13     U      15      16     17      18      I'J     20      21 

2     23      24      25      20     2T     28     29     30      31 

t    4 

Alt     I     4i      .      .      . 

.    ^                     A    4 

^4    ^      J    J    I    J 

i^      ^       ^       .                       i       r. 

""°       \  Ik  ^ 

tffu-t-Mtt- 

1  if  i    t  C  A      t  ^ 

^  i        -,      '  i    JZ  , 

,oc,°j\A^M^r 

i      1    t*^  t  I    L  i 

^t  t     i  7  ]  1  i 

100  /if^yjt  f 

f  t  t  1               jff 

I  ^    j  fi  it 

99°'^  r  '^qt  ^ 

»-    h    f                              f 

»y        r         r 

^.                       ^          / 

'  1  1 1  1 1 

98° 

J 

---  -:^V44t--Zzzz 

Fig.  28. — Stage  III.     Active  Spreading  Process  in  Both  Lungs  and  Com- 
mencing Cavity  Formation.     Continual  fever.     (Case  C.) 


The  temperature  may  be  absent,  intermittent,  remittent,  or  even,  though 
rarely,  continuous.  We  may  have  a  scarcely  recognizable  intermittent 
fever  with  a  normal  morning  or,  more  generally,  subnormal  temperature, 
and  a  very  slight  evening  rise  to  99.4°  F.,  or  a  little  later  a  more 
pronounced  intermittent  temperature  with  an  evening  rise  to  100°  F. 
or  over.  A  remittent  temperature  with  a  morning  temperature  of  99°  F. 
to  100°  F.  is  often  seen,  though  if  the  temperature  is  taken  as  early  as 
seven  o'clock  it  will  still  be  found  to  be  subnormal.  In  the  evening  such 
cases  rise  to  101°  F.,  or  in  more  severe  cases  as  high  as  103°  or  10-1:°  F., 
though  the  average  case  of  tuberculosis,  unless  far  advanced,  will  not 
generally  show  a  temperature  higher  than  103°  F.,  except  during  acute 
exacerbations. 

The  hectic  temperature  is  associated  with  the  late  stages  of  tuber- 
culosis and  extensive  ulcerating  cavities,  with  profuse  purulent  spu- 
tum, often  showing  streptococci.  There  is  a  sulmormal  morning  tem- 
perature, as  low  as  96°  F.  or  95°  F.  plus,  and  with  or  without  an  early 


SUBJECTIVE   SYMPTOMS 


163 


afternoon  chill  and  a  subsequent  rise  to  102°  to  105°  F.  The  study  of 
the  temperature  in  early  cases  is  of  great  value,  and,  as  has  been  stated, 
in  no  other  disease  do  such  relatively  slight  differences  of  temperature 
possess  such  importance. 

ilost  of  the  writers  on  the  subject,  with  the  exception  of  C.  J.  B. 
^Yilliams,  have  not  laid  sufficient  weight  on  the  significance  of  morn- 


Dec.                                                                         Jan. 
Day         27            28            29            30            31             1              i              i              4              5              6              7 

~r                  .                                                        1 

102       *                               f 

loi-^                       ±1                            -           ,, 

'"       \  Jni  t       I      .      p-     .      ^t 

100'              4t        t            itrz.ar 

t            ±    zt      ^     ^f^     H^  ±     i 

99<^  -i       -.                           1      ±     7      z:    7      p«.    , 

t      -i     ^   ^          4      J      2      f     -.^      t 

98°^l     A     v^x-  /      1      it     I     2       2       J      ^      .,* 

07  °                                                  -                                           -i 

-J                / 

I-  :±  r  +i     .-^     _  +_        :     :      :      :      ::: 

Fig.  29. 


Day 

104° 
103° 
102° 
101° 


% 


t- 


?; 


ii 


tK 


-4 


ff 


Fig.  30. 

Figs.  29  and  .30. — Non-resolvixg  Tuberculous  Pneumonia  with  Chills,  Sweats, 
Hectic  Fever,  and  Rapid  Breaking  Down  of  Lung,  with  Mixed  Infection. 
(Case  W.  G.) 


ing  subnormal  temperatures  in  such  cases.  In  the  experience  of  the 
writer,  who  has  made  two-hourly  temperature  observations  in  all  cases 
for  a  month  at  least,  and  often  for  longer  periods  of  time,  for  years, 
tlie  morning  temperature  in  tuberculosis  is  rarely  up  to  normal,  and 
tliis  subnormal  morning  temperature  is  of  real  diagnostic  value.  Often 
before  any  evening  rise  can  be  found,  the  temperature  on  waking  is 
97°  E.  or  under,  which,  however,  soon  becomes  normal,  so  that  if 
the  first  temperature  is  not  taken  early  enough,  this  subnormal  tem- 
perature will  be  overlooked. 

As  the  case  goes  on  to  arrest  or  to  apparent  cure,  the  evening  hyper- 
thermia disappears  long   before  the  patient   loses   his  morning  hypo- 


16-1:  SYMI'TO.MATOLOGY    OF    PULMONARY   TUBERC'l'l.OSIS 

tliermia.  The  evening  rise  in  early  cases  is  rarely  more  than  a  few 
tenths  of  a  degree,  and  while  Vierordt  gives  the  range  of  normal 
temperature  as  from  1)7.8"  to  ilDJi"  F.,  a  persistent  evening  rise  lu 
99.2°  F.  can  be  considered  as  fever,  providing  the  digestive  tract  is  in 
order.  A  morning  temperature  below  97.8°  can  be  considered  sub- 
normal, except  in  very  cold  weather.  Turban  ('99)  considers  a  tem- 
perature of  98.9°  F.  the  limit  of  normal  mouth  temperature,  and  a 
temperature  of  99.3°  F.,  with  the  patient  at  rest,  if  frequently  recur- 
ring, as  fever.  In  such  early  cases  there  is  generally  a  subnormal  tem- 
perature at  7  or  8  a.m.,  before  the  patient  leaves  his  bed,  which  rises 
to  normal  at  9  a.m.,  remaining  normal  until  after  midday  (though  a 
little  later  the  rise  begins  at  12  M.,  or  even  earlier),  from  which  time 
it  rises,  reaching  its  maximum  somewhere  between  2  and  6  p.m.,  gen- 
erally about  4  P.M.,  and  falling  back  to  normal  very  quickly  in  early 
cases,  more  gradually  in  more  severe  cases.  Unless  a  two-hourly  tem- 
perature record  is  taken,  this  fluctuation  is  very  easily  overlooked. 

Here  it  should  be  noted,  however,  that  if  a  1  p.m.  dinner  is  taken  or 
a  heavy  lunch,  there  will  be  a  postprandial  rise  in  temperature  within 
fifteen  minutes  or  a  half  hour  after  eating,  higher  than  the  general 
average,  and  which  does  not  give  a  true  idea  of  the  real  two-o'clock 
temperature.  This  postprandial  rise  is  normal  in  health,  but  is  mag- 
nified in  tuberculosis,  so  that  a  heavy  eater  or  a  dyspeptic  will  have 
the  highest  temperature  of  the  day  between  2  and  3  p.m.,  after  his 
midday  meal,  but  this  slight  postprandial  rise,  as  already  noted,  is  in 
ordinary  cases  separated  from  the  real  maximum,  which  usually  comes 
later.  In  view  of  this  fact,  slight  after-dinner  rises  have  of  course  less 
value  than  those  coming  at  four  or  six  o'clock,  and  it  should  also  not 
be  forgotten  that  cases  of  anemia  (as  noted  by  Papillon)  show  such  a 
rise. 

In  somewhat  more  advanced  cases  the  temperature  begins  to  rise 
about  twelve  o'clock,  rises  gradually  to  its  maximum,  and  falls  gradually, 
reaching  normal  about  eight  or  ten  o'clock  at  night,  and  falling  steadily 
after  that,  to  reach  the  lowest  point  at  about  3  a.m,  Certain  cases,  how- 
ever, and  they  are  generally  bad  ones,  have  their  maximum  in  the  night, 
and  at  times  it  may  he  necessary  for  diagnostic  purposes  to  wake 
patients  at  intervals  for  a  night  or  two  in  order  to  find  this  out. 

A  flushing  of  the  face  after  meals  is  often  noted  in  tuberculous 
patients,  even  before  a  temperature  rise  can  be  discovered,  and  this  at 
times  is  a  useful  hint. 

All  tuberculous  patients  are  easily  affected  by  both  physical  and 
mental  disturbances,  such  as  overexcitement,  overexercise,  grief,  anger, 
worry,  all  of  which  make  their  mark  on  the  temperature  curves  of  these 
sensitive  organizations.     In  apparently  afebrile  cases  one  can  disclose 


81  BJECTIVE   SYM1'T(L\1S  1()5 

;ni  otlienvise  hidden  temperature  by  ordering  a  long  walk.  In  some 
eases  the  temperature  is  depressed. 

Again,  a  patient  who  is  improving  will  lose  his  evening  rise  long 
before  his  morning  subnormal  temperature,  which  persists  until  normal 
vitality  has  been  restored,  and  no  patient  should  be  considered  as  being 
cured  until  this  subnormal  temperature  is  lost.  Even  after  a  return 
to  nornuil  and  an  arrest  of  the  process  the  temperature  is  apt  for  some 
time  to  be  easil}^  affected  by  nervous  influences. 

The  graphic  curves  of  the  majority  of  women  patients  show  a  rise 
of  tem])erature  just  preceding  and  during  the  first  two  days  of  the 
menstrual  period,  and  when,  in  a  woman,  the  temperature  is  normal 
at  ordinary  times,  it  is  wise  to  wait  for  the  next  menstrual  j^eriod 
l)efore  making  a  final  decision.  Except  in  the  case  of  very  excitable 
people,  there  is  no  subjective  sensation  of  temperature  in  this  stage, 
and  even  considerably  later,  so  that  these  patients  will  report  various 
symptoms  which  make  certain  the  presence  of  increased  temperature 
long  before  the  time  when  the  patients  themselves  have  noted  it.  Xeu- 
lotic  patients  notice  fever  much  earlier  than  others,  and  if  they  know 
that  fever  is  Ijeing  sought  for  they  will  often  note  flushed  cheeks  and  feel 
fcMrish  when  the  thermometer  shows  no  rise  of  temperature. 

It  must  never  be  forgotten,  in  studying  the  temperature  of  a  sus- 
picious case,  that  incipient  cases  often  show  periods  of  normal  tempera- 
ture, followed  by  rises  above  the  normal,  so  that  a  diagnostic  study  of 
temperature,  if  negative  at  first,  should  be  continued  for  two  weeks 
or  a  month  if  certainty  is  desired.  As  the  disease  progresses  and  evi- 
dent consolidation  appears,  the  evening  temperature  rises  to  about 
100°  F.,  or  more  rarely  to  101°  F.,  the  morning  temperature  still 
being  subnonnal,  though  it  tends  to  reach  normal  at  a  progressively 
earlier  hour. 

The  course  of  the  temperature  is  also  marked  by  occasional  more 
active  rises  as  new  areas  of  involvement  manifest  themselves.  This 
irregularity  of  course  is  very  typical  of  the  temperature  of  tuberculosis, 
and  while  at  times  the  curve  remains  unchanged  for  months,  it  is  not 
the  rule,  the  graphic  curve  of  the  average  case  showing  very  beautifully, 
l»y  the  perturbations  of  its  course,  the  various  harmful  influences  which 
affect  the  patient. 

The  graphic  curve  is  a  very  valuable  aid  in  the  study  of  the  patient, 
and  should  be  noted  in  all  cases  for  the  first  few  weeks  at  least,  and 
in  some  cases  foi-  a  longer  time.  As  a  general  I'ule,  a  poussee  dc 
rongestion,  as  the  French  term  the  exacerbations  so  typical  of  the; 
dist'jise.  does  not  come  on  suddenly,  but  is  preceded  by  two  or  three  days 
of  slowly  rising  temperature  and  accelerating  pulse  liefore  any  otlici' 
symptoms  show  themselves.     'J'his  gives  the  doctoi'  an  invaluable  oppor- 


166 


SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 


tiinity   to  attack  and  cut  short  the  congestion  before  it  gets    beyond 
control. 

Digestive  disturbances,  so  common  in  tuberculosis,  generally  produce 
a  sudden  and  much  higher  rise,  which  usually  begins  earlier  in  the  day, 
with  symptoms  of  gastric  discomfort.  The  prompt  removal  of  such 
complaints  by  means  of  calomel  and  starvation  lays  bare  their  nature. 
Some  cases  of  temperature  of  moderate  degree  but  great  obstinacy  dis- 
appear completely  on  the  discovery  and  correction  of  gastric  dilatation 
and  stasis,  and  such  cases  demonstrate  the  close  and  important  relation 
of  stomach  conditions  to  the  course  of  tuberculosis. 


Day  20  21  22  23  24  25   2U  27  28  29  3U   l   2   J      4       5   0   7   8   U   10  11  12  13  U 


10i° 
103° 


^^7-lP^^^^-^-^--^-^^^-'~- 


^m 


5 


^5j- 


Fio.  31. 


June                                                                                                                           July 
Day     13     14      15     10     17      18     10     20     21     22     23     24     25     28     27     28     29     30      1       2       3      4       5       6       7 

102 

A  ^      a\  ,.     \  ^          ^ 

100°                                      \       H>.        S    A   :    1^-^ 

-J J    v\t  y  t^       \\ 

99°           _,:,          H^      *^^3i       ^11*      X 

=4h\,-3\.S           {                                        ^^^^^-^-1%   vjs^^^"-"* 

98°     \   i  ^  ^  i      y                              ^  *      *  ^ 

97°  I 

Fig.  32. 

Figs.  31  and  32. — Stage  III.     In.yctive,  Showing  Effect  of  Oveuexertion 
(Railroad  Journey)  .\nd  of  an  Acute  Bronchitis.     (Case  L.  R.) 


Even  acute  pneumonic  attacks  are  generally  preceded  by  a  slow  rise 
in  temperature  before  the  sudden  ascent  in  temperature  and  chill  which 
usher  in  the  actual  attack.  Ischiorectal  abscesses,  for  some  time  before 
they  trouble  the  patient  sufficiently  to  draw  attention  to  the  seat  of  the 
trouble,  affect  the  temperature  considerably.  In  a  case  seen  by  the 
writer,  an  afternoon  temperature  of  100°  to  100.8°  F.  persisted  for 
several  weeks  before  the  patient  felt  any  pain  or  inconvenience  in  the 
rectum,  but  when  this  appeared  and  a  small  abscess  containing  not  more 
than  two  drachms  of  pus  was  evacuated,  the  temperature  dropped  to 


SUBJECTIVE   SYMPTOMS 


167 


nearly  normal  and  has  remained  there  ever  since.  Therefore,  it  is 
necessary  to  make  sure  that  the  increased  temperature  is  not  due  to 
extrapulmonary  causes  before  it  is  ascribed  to  the  lung  condition. 
When,  in  a  case  of  tuberculosis  with  fairly  extensive  lesions,  there  is  a 
persistent  low  temperature  with  symptoms  more  mild  than  the  extent 


Sept. 


Fig.  33. — St.^^ge  II.  Showing  Effect  of  Intercurrent  Bronchopneumonia 
ON  Fever  Curve.  Fall  by  lysis  and  recovery.  Patient  made  complete  recov- 
ery.    (Case  C.  M.  C.) 


of  the  trouble  would  seem  to  justify,  it  should  always  suggest  the  pos- 
sibly fibroid  nature  of  the  case,  such  a  temperature  record  being  very 
characteristic  of  this  type  of  cases. 

As  the  process  reaches  the  third  stage,  with  extreme  infiltration 
and  destruction  of  tissue,  with  excavation,  the  temperature,  as  a  rule, 
ranges  from  101°  F.  up,  the  rise  coming  on  as  early  as  ten  or  eleven 
o'clock  in  the  morning,  or  not  later  than  midday,  and  lasting  until 
quite  late  at  night.  This  long-continued  fever  naturally  severely  affects 
the  patient's  constitution.  Softening  of  involved  areas  is  generally 
accompanied  by  high  and  obstinate  temperatures  which  will  not  fall 
until  the  necrotic  area  is  sufficiently  softened  to  be  expectorated. 

Cavities  whose  contents  tend  to  collect  and  dam  up  instead  of  being 
expectorated  freely,  will  also  cause  rises  of  temperature,  though  not 
being  accompanied  by  inflammation  the  rise  is  not  generally  as  high 
as  is  that  caused  by  softening  of  lung  tissue,  but  is  rather  of  a  hectic 
type,  and  it  falls  when  the  pus  is  expectorated.  These  are  the  cases 
in  which  posture  aiming  at  emptying  such  ill-draining  spaces,  is  so 
effective. 

When  excavation  is  extensive  and  drainage  is  poor,  an  irregular  re- 
mittent or  hectic  type  of  fever  appears,  marked  by  a  very  low  subnormal 
morning  tem})erature  and  high  but  irregular  afternoon  rises,  often  pre- 
ceded by  chills  and  followed  by  sweats,  and  associated  with  rapid  emacia- 
tion. There  is  generally  a  profuse  purulent  expectoration  which,  even 
when  properly  collected  and  washed,  shows  swarms  of  streptococci.    This 


168 


SYMITOMAroLCXiY    OF    PULMONARY   TUBERCULOSIS 


is  generally  considered  as 


o  -^ 


5  >  « 

t^  W  X 

cc  ^  0) 

"^  §  a 

r  O  C 

w  a;  _ 

o  g-g 

g  Q  53 

M  W  m 

rn  "-^  t- 

o  9  q 

W  J  S 


c^  ?i 


justifying  a  diagnosis  of  mixed  infection — • 
that  is,  the  existence  and  j)athogenic  activ- 
ity in  the  lung  of  other  organisms  along 
with  the  tubercle  bacillus,  usually  the 
streptococcus. 

Many  excellent  authorities  deny  the  ex- 
istence of  this  condition  and  have  brought 
forward  considerable  experimental  proof 
against  mixed  infection,  but  the  clinical 
evidence,  which,  after  all,  should  have  the 
greater  weight  in  coming  to  a  decision 
in  this  matter,  seems  to  justify  the  be- 
lief that  the  symptoms  spoken  of  are  not 
produced  by  the  tubercle  bacillus  alone, 
but  demand  tlie  cooperation  of  pyogenic 
microorganisms. 

In  these  late  cases  there  may  be  in  rare 
instances  a  typus  inversus,  in  which  the 
night  and  early  morning  temperature  is 
high,  and  the  midday  and  evening  tem- 
perature low.  Its  presence  is  always  omi- 
nous. The  writer  has  noted  in  a  few  cases 
of  hectic  fever  that  any  attempt  to  lower 
the  temperature  by  means  of  coal-tar  anti- 
pyretics produces  such  a  typus  inversus,  the 
cause  of  the  fever  being  so  active  that  when 
it  is  repressed  at  the  usual  hour  it  reap- 
pears at  another. 

In  old  cases,  with  moderate  activity  and 
large,  relatively  dry  cavities,  with  tendency 
to  fibrosis,  it  is  not  at  all  rare  to  see  a  nor- 
mal or  nearly  normal  temperature  present 
for  months,  and  while  not  improving  the 
ultimate  outlook,  it  is  of  benefit  in  so  far 
as  it  allows  of  better  nutrition  and  rest,  and 
adds  to  the  patient's  comfort.  A  double  or 
triple  rise  of  temperature  in  twenty-four 
hours,  punctuated  with  sweats,  occasionally 
occurs.     It  is  a  bad  prognostic  sign. 

A  temperature  remaining  persistently 
above  101°  F.,  despite  absolute  rest  in  bed 
in  the  fresh  air  and  proper  dieting,  is  a 
uniformly   unfavorable   sign,   speaking   for 


SlBJECTnE    SVMrXOMS  1(39 

wide  dissemination  and  a  rapid  spread  of  the  disease,  and  unless  the 
system  can  be  given  strength  enough  to  conquer  it,  a  downward  course 
and  a  fatal  termination  may  be  anticipated. 

]!^ot  infrequently  the  patient,  despite  rest  in  bed  in  the  fresh  air, 
runs  a  persistent  temperature  for  weeks.  When  these  patients  are  gotten 
out  of  bed  and  allowed  to  sit  up  a  little  and  to  walk  around,  the  tem- 
perature, contrary  to  expectation,  gradually  drops  to  normal.  The 
writer  has  noted  this  in  numerous  cases,  and  can  vouch  for  its  accu- 
racy, although  he  cannot  explain  it.  unless  on  the  ground  ^that  the  tem- 
perature is  due  to  a  disordered  digestion,  which  erect  posture  and  a 
less  sedentary  life  improved.  Except  in  old.  dry,  fibroid  cavity  cases, 
where,  as  noted  above,  there  may  be  a  good  temperature  record  with  a 
hopeless  outlook,  a  gradual  fall  of  temperature  is  almost  always  evi- 
dence of  a  lessened  activity  of  the  process  in  the  lung  and  an  improved 
prognosis. 

In  advanced  cases  there  may  at  times  be  sudden  drops  in  tempera- 
ture. These  speak  either  for  the  approach  of  the  end  or  for  shock 
accompanying  the  occurrence  of  a  pneumothorax. 

The  bad  effect  of  fever  on  the  patient's  digestion  is  so  great  that 
everything  possible  should  be  done  to  control  it.  The  patient  with 
a  high  temperature  has  neither  appetite  nor  digestive  ability.  After 
he  eats,  his  temperature  is  greatly  increased,  and  it  is  necessary  to 
arrange  meals  so  that  the  heaviest  meal  is  taken  at  the  time  of  the 
least  fever.  In  such  cases  coal-tar  antipyretics  may  be  vised,  if 
necessary.  In  advanced  cases  the  morning  appetite  is  apt  to  be 
wanting,  and  these  patients  should  eat  late  in  the  evening,  after  the 
fever  falls. 

Continuous  fever  is  rare  in  tuberculosis,  occurring  only  during  the 
existence  of  complications  or  in  acute  cases.  Remittent  fever  is  the  rule. 
It  is  unfortunate  that  so  frequently  fever  is  initiated  by  a  chill  and 
followed  by  sweats,  and  is  intermittent,  because  this  often  gives  rise 
to  a  diagnosis  of  malaria,  which  mav  cause  the  loss  of  much  precious 
time.  In  view  of  this,  it  need  hardly  be  said  that  such  symptoms,  even 
if  appearing  in  a  malarial  region,  should  suggest  not  simply  a  search 
for  the  parasite  of  malaria  in  the  blood  but  a  careful  examination  of 
the  lungs. 

Chills. — In  the  incipiency  of  chronic  tuberculosis,  chills  are  rare, 
save  a  slight  temporary  chilliness,  Avhich,  if  inquired  for,  may  be  dis- 
covered. 

As  a  rule,  it  is  only  in  acute  pneumonic  phthisis,  or  in  acute  miliary 
tuberculosis,  that  there  occur  pronounced  chills  in  the  beginning.  In 
the  second  stage  they  are  also  rare,  except  when  they  usher  in  a  con- 
gestion or  some  complication.  In  the  third  stage,  especially  if  severe 
13 


170 


SUBJECTIVE  SYMPTOMS  171 

mixed  infections  exist,  the}'  are  common,  generally  occurring  early  in 
the  afternoon  and  preceding  high  rises  of  temperature. 

Hoarseness. — In  delicate  people,  who  are  apt  later  to  develop  tuber- 
culosis, the  voice  is  weak  or  it  has  a  tendency  to  become  husky  on  changes 
of  weather. 

In  a  few  early  cases  there  is  pronounced  hoarseness,  due  either  to  a 
slight  adductor  paralysis  from  gland  pressure  on  the  recurrent  nerve 
or  a  slight  catari'h,  and  Schaffer  ('83)  considers  this  an  early  symp- 
tom ;  but  slight  hoarseness  can  be  caused  by  so  many  other  conditions 
that,  while  it  justifies  a  careful  examination  of  the  whole  respiratory 
tract,  it  cannot  be  considered  diagnostic.  In  more  advanced  cases  hoarse- 
ness from  a  simple  catarrh  is  often  seen,  but  if  it  persists  it  strongly 
suggests  tuberculous  larj^ngitis.     (See  Larynx.) 

Sweats. — ^Vhi]e  sweats  are  a  very  common  s^'mptom  in  tul:)erculosis, 
this  does  not  apply  to  the  early  stages  of  the  disease,  where  they  are  not 
often  seen,  although  a  tendency  to  undue  moisture  of  the  skin  of  the 
forehead,  neck,  chest,  and  abdomen  on  slight  exertion,  or  if  the  room 
is  rather  warm,  is  often  noted.  Profuse  sweats  in  earl}^  cases,  as  re- 
ported by  such  a  good  authority  as  Sokolowski  ('OG),^  the  writer  has 
not  seen.  The  nervous  strain  of  a  physical  examination  is  apt  to  cause 
profuse  sweating  in  the  axilla-,  but.  though  it  has  been  classed  as  such 
by  some,  this  cannot  be  called  a  symptom  of  tuberculosis  as  it  may 
occur  in  any  nervous  individual. 

In  the  second  stage  sweats  are  a  common  and  typical  symptom. 
They  generally  occur  in  the  night,  usualh'  shortly  after  going  to  sleep, 
and  are  often  repeated  again  in  the  early  morning;  but  they  may  occur 
at  other  times,  especially  after  overexertion  or  if  the  patient  dozes  in 
his  chair.  They  are  closely  associated  with  the  fever,  and  I  have  not 
known  them  to  occur  in  really  afel)rile  cases,  but,  unlike  the  sweats 
of  malaria  and  the  acute  infections,  they  do  not  promptly  follow  on 
the  fall  of  temperature  in  every  case,  although  the  night  sweat  generally 
does  so. 

In  this  stage  sweats  are  rarely  profuj^e  or  obstinate,  and  disappear 
with  few  exceptions  without  any  especial  medication  shortly  after  the 
beginning  of  an  outdoor  rest  life  and  proper  hygiene.  So  generally 
is  this  true  that  the  sweats  in  the  second  stage  rarely  need  cause  any 
anxiety,  and  one  may  count  almost  with  certainty,  on  their  ceasing 
within  one,  or  at  most  two,  weeks  of  the  commencement  of  an  outdoor 
rest  cure. 

In  these  cases  the  patient  goes  to  bed  feeling  well,  and  on  arising 
next  morning  finds  his  night  clothes  moistened  around  his  neck  and 
chest,  but  he  is  not  generally  disturbed  by  the  sweat  unless  it  is  quite 
profuse.     If  it  is  profuse,  he  is  awakened  shortly  after  going  to  sleep 


172  SYMPTON[ATOI.OfiY    OF    prLMOXARY   TIBERCri^OSLS 

by  a  "  gone '"'  sensation,  to  find  his  night  clothing  wringing  wet.  After 
a  change  of  clothing  he  falls  to  sleep  again,  to  he  awakened  in,  the 
early  morning  by  a  repetition  of  this  occurrence.  Patients  very  soon 
learn  that  heavy  bedding  favors  sweats,  as  does  free  water  drinking  or 
hot  drinks,  and  in  light  cases  proper  attention  to  these  causes  is  at 
times  sutticient  to  prevent  sweats. 

Tn  the  Ihird  stage  cases  the  sweats  form  a  very  serious  and  trouble- 
sonie  featuic  of  the  case,  exhausting  tlie  strength  of  the  patient  and 
])mducing  the  greatest  discomfort.  Such  patients  soak  the  sheets  .sev- 
eral times  a  night,  and  their  sleep  is  greatly  disturbed,  and  even  in  the 
daytime,  if  they  sleep,  the  sweats  appear.  These  '"colliquative  sweats" 
are  most  obstinate  and  often  fail  to  yield  to  any  treatment. 

The  view  of  Cornet  ('07),  who  ascribes  the  sweats  to  the  action  of  a 
toxin  of  the  tubercle  bacillus,  or  other  bacteria  on  the  sweat  or  heat 
regulative  centers,  is  now  generally  accepted. 

While  many  excellent  authorities  deny  that  the  various  pus  organ- 
isms play  any  part  in  the  symptomatology  of  tuberculosis,  the  clinical 
picture  in  the  late  stages  is  so  similar  to  that  of  septic  infections  that 
it  is  difficult  to  think  that  the  streptococcus  or  other  pus  organisms  have 
not  some  part  in  producing  the  sweats  of  this  stage.  By  no  means, 
however,  do  all  advanced  cases  sweat ;  fibroid  cases  rarely  present  this 
symptom  unless  there  are  present  secreting  cavities. 

Languor. — There  are  few  early  symptoms  of  tuberculosis  more  sug- 
gestive than  languor,  yet  none  is  so  often  ascribed  to  other  causes,  the 
undue  weariness  which  marks  the  beginning  of  <o  many  cases  being 
taken  for  anything  rather  than  tuberculosis.  In  a  majority  of  the 
writer's  cases  it  was  the  first  symptom  noted  by  the  patient,  and  per- 
sistent weariness  should,  of  itself,  be  a  sufficient  reason  for  the  most 
careful  examination  of  a  patient's  lungs.  To  those  who  have  not  expe- 
rienced it,  it  is  difficult  to  describe  the  utter  weariness  that  such  patients 
feel,  without  any  apparent  reason,  and  chiefly  in  the  afternoon,  when 
the  temperature  is  rising ;  but  it  is  often  present  when  no  temperature 
is  suspected. 

The  whole  body  seems  filled  with  "tiredness"";  even  to  breathe  is 
an  effort,  and  if  the  patient  lies  down  to  rest,  weariness  seems  to  run 
through  his  limbs.  They  ache  with  fatigue  and  seem  to  pin  him  to 
the  bed.  Later  in  the  evening  this  feeling  pas.ses  off  and  the  patient 
often  feels  very  well.  On  waking,  a  heretofore  active  man  will  find 
himself  not  rested  or  refreshed  and  with  no  ambition  for  work,  and 
many  such  a  one  has  feared  he  was  getting  lazy  or  has  taken  to  bracing 
himself  with  alcoholics,  or  has  had  a  diagnosis  of  neurasthenia  made 
on  account  of  it. 

This  w^eariness  can  often  be  overcome  by  taking  food  between  meals 


SIBJEGTIVE   SYMPTOMS  173 

or  at  the  lime  when  tlie  fatigue  comes  on,  but  it  has  not  any  connection 
Avith  the  anorexia  of  early  tuberculosis,  being  a  distinct  toxemia. 

Later  in  the  disease,  possibly  because  the  system  has  accustomed  itself 
to  the  effect  of  the  intoxication,  this  symptom  becomes  less  marked,  and 
nothing  is  more  astonishing  than  the  activity  and  obliviousness  to 
fatigue  of  the  tuberculous  patient  who  has  considerable  trouble  and 
marked  fever.  In  the  late  stages  weariness  is  again  present,  but  it  is 
then  due  to  extreme  tissue  waste  and  inadequate  nutrition. 

Emaciation. — Loss  of  weight  has  from  the  earliest  times  been  one 
of  the  symptoms  which  has  chiefly  attracted  attention,  as  is  shown  by 
the  name  '^  phthisis,"'  from  the  Greek  <^^tcris  (a  wasting  away).  It  fre- 
quently appears  quite  early,  but  is  not  generally  present  in  the  incipient 
stage,  though  a  gradual  loss  of  weight,  without  evident  reason  should, 
like  languor,  arouse  suspicion  as  to  the  condition  of  the  lungs.  When 
the  process  becomes  sufficiently  pronounced  to  give  evident  signs  of 
softening,  it  is  practically  never  absent  in  an  untreated  case,  the  excep- 
tions being  so  unusual  as  only  to  prove  the  rule,  while  it  is  uniformly 
and  progressively  present  in  all  severe  cases,  and  goes  hand  in  hand 
with  the  advance  of  the  trouble,  affecting  not  only  the  muscles  and  fat, 
but  every  organ  of  the  bodv. 

On  the  other  hand,  a  gain  in  weight  has  long  been  recognized  as 
one  of  the  most  favorable  ])rognostic  signs.  The  patient  who  is  stead- 
ilv  increasing  in  avoirdupois  is  almost  always  improving  in  his  pul- 
inonary  condition,  though  temporary  gains,  quickly  made,  are  of  little 
significance. 

L.  Brown,  in  a  careful  study  of  the  weight  of  the  patients  of  the 
A(lii'(mdack  Cottage  Sanatorium  ('03)  says:  "A  regular,  constant,  un- 
interrupted gain  of  weight  continued  for  two  months  is  of  favorable 
prognostic  import,  but  the  gain  of  a  few  pounds  is  not  a  sure  sign 
of  improvement." 

Loss  of  weight,  in  the  beginning,  is  probably  of  toxic  origin,  but 
later  it  is  closely  related  to  the  fever  and  the  anorexia,  and  generally, 
except  in  hopelessly  advanced  cases,  or  where  intestinal  involvement 
exists,  disap])ears  to  a  great  extent  when  the  temperature  falls  and  when 
the  appetite  is  fully  restored.  However,  it  must  never  be  forgotten 
tliat  some  patients  with  large  appetites  continue  to  lose  weight.  In 
addition  to  a  decreased  intake  of  food  there  seems  to  be  a  greatly  low- 
ered absorptive  power  in  the  intestinal  canal,  possibly  related  to  that 
congenital  narrowing  of  the  lympli  channels  which  has  been  claimed  to 
exist  in  this  disease  by  some  authors. 

People  with  constitutionally  ])0()r  weiglit-gainiiig  altility,  as  well  as 
those  with  habitually  poor  appetites,  are  unduly  ])rone  to  develop  tuber- 
culosis, possibly  owing  to  habitual   undcr-nourishmcnt  of  the  cells  and 


174    SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

consequent  lowering  of  their  resisting  power.  The  dyspepsia  so  common 
in  these  cases  should  also  not  be  overlooked,  as  its  removal  often  affects 
the  weight  favorably.  As  has  been  said,  however,  the  loss  of  weight 
in  the  early  stages  is  jjrobably  toxic.  Cornet,  who  is  a  great  believer 
in  the  effects  of  the  poisons  of  the  bacillus  on  the  body,  recalls  the 
well-known  experiments  in  which  the  injection  of  cultures  of  the  dead 
bacilli  into  animals  has  produced  marasmus. 

The  loss  of  weight  is  apt  to  show  itself  first  around  the  tnmk,  espe- 
cially in  women  patients.  In  the  early  stage,  at  least,  it  is  not  apt  to 
affect  the  face,  so  that  the  physician  may  be  deceived  as  to  the  patient's 
real  nutrition,  unless  he  inspects  the  thorax  and  abdomen.  Eegained 
flesh  is  first  noted  on  the  abdomen,  chest,  and  hips. 

In  advanced  cases  the  high  fever,  with  the  accompanying  tissue 
waste,  added  to  the  decreased  tissue  formation,  produces  extreme  degrees 
of  emaciation,  with  great  wasting  of  the  muscles.  Here  we  get  the 
prominent  cheek  bones  and  nose,  with  the  dry,  thin,  branny  skin  drawn 
tightly  over  the  bony  prominences,  and  sinking  into  the  hollows  between, 
which  for  centuries  has  made  the  graphic  term  "  consumption  "  a  terror 
to  layman  and  physician  alike.  In  arrested  cases  the  patient,  even 
when  he  has  regained  his  strength  and  efficiency,  is  very  apt  never  to 
return  completely  to  his  previous  normal  weight,  but  ahvays  to  run  a 
few  pounds  below.  To  this  rule  there  are  many  exceptions,  certain 
patients  after  a  climatic  and  hygienic  cure  reaching  and  maintaining 
a  weight  never  enjoyed  before,  and  we  are  justified  in  considering  such 
cases  unusually  favorable. 

The  chief  gains  in  weight  are  made  in  the  winter  months,  most 
favorable  cases  (in  Asheville)  gaining  from  October  to  April  or  May, 
and  falling  off  to  a  moderate  degree  during  the  summer,  to  recom- 
mence gaining  again  in  October.  Berger  ('05),  in  the  Basel  Sanato- 
rium at  Davos,  found  that  women  gained  more  slowly  than  men,  and 
that  people  ])etween  thirty  and  forty  were  the  best  weight  gainers. 

The  total  weight  lost  in  bad  cases  is  given  by  Euehle  ('87)  as  from 
one  third  to  one  quarter  of  the  normal  weight,  a  loss  which  Chossat 
found  sufficient  to  kill  dogs,  but  coming  on  gradually  in  phthisis,  it 
is  tolerated  remarkably  well.  While  patients  will  at  times  gain  weight 
very  rapidly  for  a  few  weeks,  even  up  to  one  pound  a  day,  this  is 
unusual,  and  it  is  more  usual  to  find  cases  gain  from  half  a  pound  to 
two  pounds  a  week  in  the  winter  season  and  less  in  summer. 

In  the  first  weeks  or  months  of  a  hygienic  cure  the  patient,  if  doing 
well,  generally  gains  rapidly,  often  putting  on  one  or  two  or  even  more 
pounds  a  Aveek  for  a  number  of  weeks,  but  as  he  approaches  his  normal 
weight  the  rapidity  of  gain  slows  down,  and  when  he  passes  this  point, 
further  gains  are  usually  at  a  rate  of  one  quarter  or  one  half  pound 


SUBJECTIVE   SYMPTOMS  175 

a  week.  Intercurrent  disease  stops  weight-gaining,  but  if  transient, 
and  if  the  case  is  a  favorable  one,  gain  of  weight  will  begin  again  after 
recovery  from  the  disease. 

Patients  who  indulge  in  alcoholics  will  generally  put  on  weight 
rather  rapidly,  which  is,  perhaps,  one  of  the  reasons  alcohol  has  been 
so  much  used  in  this  disease,  but,  unlike  weight  normally  gained,  it  is 
not  accompanied  by  gain  in  strength ;  the  patients  get  "  puffy  "  and 
"  flabby,"  and  the  general  condition  is  not  improved  but  injured.  Fi- 
nally, it  should  be  noted  that  each  patient's  weight  should  be  studied  in 
relation  to  his  height,  as  in  the  tables  used  by  insurance  companies, 
and,  according  to  Papillon  ('97),  also  in  its  relation  to  the  thoracic 
perimeter. 

Anorexia. — Anorexia,  while  generally  classed  as  a  gastric  symptom, 
is  more  correctly  considered  as  a  constitutional  one,  arising  at  first  more 
from  the  toxemia  incidental  to  the  disease  than  from  the  condition  of 
the  stomach  itself.  This  symptom  is  one  of  the  very  earliest,  and  is 
apt  to  manifest  itself  first  rather  as  a  fastidiousness  as  to  food  than  as 
a  real  disinclination  to  eat.  Nothing  is  cooked  quite  right  or  tastes 
quite  as  it  should,  but  before  long  this  runs  into  a  real  lack  of  appetite. 

Many  patients  for  years  have  been  light,  fickle,  "  finicky  "  eaters, 
so  that  we  can  be  in  doubt  as  to  whether  the  symptom  is  a  result  or  a 
cause  of  the  trouble.  Many  others  have  always  eaten  a  poor  breakfast 
but  a  good  dinner  and  supper,  and,  in  the  writer's  experience,  anorexia, 
when  it  first  manifests  itself  in  tuberculosis,  is  apt  to  affect  the  morning 
appetite  chiefly.  It  is  by  no  means  an  index  of  poor  digestive  power, 
and  when  such  cases  force  their  appetites  beyond  their  desire,  though 
not  beyond  a  reasonable  amount  of  food,  they  often  digest  excellently 
and  fatten.  The  same  has  frequently  been  noted  with  patients  on 
gavage,  or  forced  feeding. 

The  effect  in  this  stage  of  the  disease  of  fresh  air  and  outdoor  life, 
with  the  consequent  increased  oxygenation  of  the  blood,  is  often  most 
remarkable,  and  we  are  justified  in  feeling  anxiety  as  to  a  patient  who, 
under  such  conditions,  fails  to  develop  a  desire  for  food.  In  moderately 
advanced  cases  we  find  at  times  very  pronounced  anorexia,  the  patient 
is  disgusted  by  food  even  to  the  point  of  vomiting  at  the  sight  of  it, 
and  can  force  it  down  his  throat  only  with  difficulty.  More  commonly, 
however,  there  is  a  moderate  desire  for  food,  but  the  first  few  mouth- 
fuls  bring  a  sense  of  repletion,  and  the  patient  thinks  he  can  eat  no 
more.  Tliese  are  the  cases  where  it  is  necessary  to  compel  the  patient 
to  chew  and  swallow  food  against  his  will,  ^^^latever  the  cause  of  the 
anorexia  in  early  and  moderately  advanced  cases,  in  the  third  stage  it 
can  unquestionably  be  ascribed  chiefly  to  the  high  temperature,  with 
its  resultant  anachlorhydria,  although  Miiller  ('04)  denies  the  latter. 


176    SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

A  patient  iu  this  stage,  wiio  may  have  a  very  good  breakfast  appe- 
tite, will  by  midday,  and  from  that  time  until  the  temperature  falls 
again,  have  no  desire  for  food,  partly  due  to  his  fear,  bred  of  experience, 
that  eating  will  send  up  his  temperature.  AYhen  later  in  the  evening  the 
temperature  has  fallen,  these  patients  will  often  be  able  to  take  food 
with  some  relish,  and  it  will  sometimes  be  necessary  to  cut  down  the 
;i mount  of  food  during  the  fever  hours  to  a  minimum  and  push  it  at 
other  times.  In  late  cases  distaste  for  food  is  sometimes  due  to  dys- 
jjhagia  caused  by  a  tuberculous  laryngitis. 

The  bulimia  seen  in  some  cases  of  tuberculous  enteritis,  with  gland- 
ular involvement,  should  here  be  noted.  So  characteristic  is  this  raven- 
ous appetite  in  this  condition,  that  it  has  great  diagnostic  importance. 
While  there  are  no  abnormal  cravings,  there  is  often  an  aversion  for 
just  those  foods  which  are  l)est — i.  e.,  meats  and  fats.  Such  a  dislike 
is  very  common  and  very  difficult  to  overcome. 

A  perfectly  normal  appetite  is  often  found,  but  only  in  those  cases 
with  the  best  outlook.    It  is  an  admirable  prognostic  sign. 

Dyspnea. — In  pulmonary  tuberculosis  dyspnea  is  of  two  kinds,  of 
widely  differing  import.  In  acute  miliary  tuberculosis,  or  in  the  begin- 
ning of  acute  phthisis,  dyspnea  is  an  early  symptom,  and  is  probably 
due  to  irritation  of  the  vagus  terminals  by  the  innumerable  tubercles 
and  to  the  physical  effect  of  their  presence  on  the  respiratory  capacity 
of  the  lungs,  as  well  as  to  the  systemic  effect  of  the  toxins.  In  this 
form  it  is  usually  accompanied  by  cyanosis. 

In  the  beginning  of  the  more  chronic  form  of  tuberculosis  it  is 
not  found,  although  some  authors  consider  it  an  early  symptom. 
Blancard  ('07)  quotes  Arthaud,  who  describes  a  ])eculiarly  dyspneic 
facies  which  he  thinks  diagnostic  of  tuberculosis:  "The  characteristic 
thing  in  the  tuberculous  facies,  even  at  the  beginning  of  the  period  of 
invasion,  is  the  permanent  spasm  of  the  respiratory  apparatus  which 
gives  the  face  that  expression  of  suffering  Avhich  one  notices  with  the 
last  symptoms  in  hopeless  cases.  The  dilatation  of  the  nostrils,  accom- 
panied or  not  Ijy  emaciation  of  the  face,  shovdd  cause  us  always  to  sus- 
pect tuberculosis." 

In  his  own  early  cases  the  writep  has  noted  on  his  charts  the  aku 
of  the  nose  and  the  facies  in  all  patients,  and  has  not  been  able  to 
verify  this  observation.  Some  shortness  of  breath  on  exertion  or  on 
talking  will  often  be  complained  of,  or  noted  by  the  physician,  but  it 
is  not  sufficiently  marked  to  have  great  diagnostic  value.  The  dyspnea 
of  moderately  advanced  cases  is  chiefly  noted  on  exertion,  and  while  it 
can  be  increased  by  cough,  eating,  or  fever,  it  is  always  relieved  by  rest. 
It  is  probably  due  at  this  time  to  lessened  lung  area,  or  possibly,  as 
Fox  suggests,  to  the  lessened  amount  of  blood  to  carry  on  the  systemic 


SUBJECTIVE   SYMPTOMS  177 

respiration,  though  as  it  is  found  at  times  in  the  full-blooded,  this 
would  seem  doubtful,  but  his  added  explanation  that  it  is  due  to  com- 
pensatory emphysema  seems  improbable.  It  can  also,  however,  be  pro- 
duced in  a  severe  form  by  the  pressure  of  enlarged  bronchial  glands  on 
the  pneumogastric  nerve,  and  in  the  neurcrtic,  like  all  other  symptoms, 
it  will  be  found  uiiduly  magnified,  though  it  is  probably  not  of  nervous 
origin  as  some  teach. 

The  formation  of  much  fibroid  tissue  in  the  lungs  is  responsible  for 
the  development  of  a  very  slow  and  gradually  increasing  dyspnea,  whicli 
can  be  so  marked  as  even  to  persist  during  rest ;  and  a  gradually  increas- 
ing sliortness  of  breath  in  a  patient  otherwise  doing  well,  should  strongly 
suggest  the  presence  of  marked  and  extensive  fibrosis.  An  extensive 
old  pleurisy  can  so  ]>ind  down  the  lungs  as  to  cause  dyspnea. 

The  sudden  development  of  dyspnea  at  this  stage  is  generally  of 
serious  import,  and  speaks  for  extension  of  the  area  of  involvement  or 
possibly  for  pleuritic  effusion.  Apparently  causeless  dyspnea,  in  cases 
without  marked  limitation  of  respiratory  area,  should  always  excite 
suspicion  of  an  acute,  or  at  least  a  very  general,  dissemination.  It  is 
found  quite  frequently  in  those  subacute  cases  w^hich  present  the  signs 
of  a  miliary  tuberculosis,  but  which  run  a  relatively  slow  but  uni- 
formly fatal  course. 

A  case  in  point  seen  by  the  writer  was  that  of  a  girl  of  twenty-four, 
with  tuberculosis  of  a  relatively  slow  course,  and  with  no  sign  of  exten- 
sive infiltration,  but  rather  of  disseminated  tubercles.  There  was  a 
]U'(mounced  dyspnea  of  obscure  origin,  and  the  bad  prognosis  based 
largely  on  this  symptom  was  borne  out  by  the  subsc(|uent  history.  In 
some  cases  where  the  dyspnea  is  not  noted  in  the  daytime  there  are 
severe  asthma-like  attacks  in  the  night,  but  these  generally  yield  to 
potassium  iodid.  They  were  probably  ordinary  cases  of  asthma  in  tuber- 
culous subjects. 

In  advanced  cases  the  degree  of  dyspnea,  in  spite  of  the  extensive 
destruction  of  lung  tissue,  is  astonishingly  small;  except  on  exertion, 
the  dyspnea  of  tuberculosis,  as  West  notes  ('02),  bearing  a  much  closer 
I'elation  to  the  rate  of  development  of  the  disease  than  to  its  extent. 
Thus  the  gradual  development  of  the  process  in  tuberculosis  gives  Nature 
time  to  bring  into  play  her  wonderful  adaptability  to  new  conditions, 
and  it  is  only  when  such  time  is  not  allowed,  as  in  rapid  disseminations, 
sudden  pleural  eifusions,  or  more  especially  in  pneumothorax,  that 
d3^spnea  can  be  e.xeessive,  agonizing,  and  at  times  fatal.  When  the 
moderate  dyspnea  of  third-stage  cases  is  spoken  of,  it  must  be  recalled 
that  such  cases  are  usually  at  rest;  v/hen  from  their  financial  condition 
they  are  obliged  to  keep  up  physical  exertion,  dyspnea  can  be  a  very 
painful  feature  and  one  that  cannot  be  relieved. 


178  SYMPTOMATOLOGY   OF   PULMONARY   TUBERCULOSIS 

Cyanosis. — Cyanosis  is  not  ordinarily  seen  in  the  chronic  forms  of 
pulmonary  tuberculosis,  though  some  degree  of  cyanosis  of  the  finger 
tips  and  of  the  face  is  found  in  advanced  cases  or  where  there  is  rapid 
dissemination,  and  it  is  also  to  be  seen  in  the  clubbed  fingers.  In  acute 
miliary  cases,  however,  it  is  an  early  and  alarming  symptom. 

The  Circulatory  System. — The  circulatory  system  very  early  in  tuber- 
culosis undergoes  modifications  which  aft'ect  both  the  pulse-rate  and  the 
blood-pressure.  Tachycardia  appears  very  early  in  the  disease,  and,  in- 
deed, often  exists  for  a  considerable  time  befm'e  any  pulmonary  lesion 
can  be  discovered,  so  that  those  who  have  assumed  the  existence  of  a 
"  pretuberculous  state  "  have  picked  this  out  as  one  of  its  most  marked 
symptoms.  While  not  admitting  the  existence  of  such  a  state,  the  active 
presence  of  the  bacillus  in  the  body  before  it  can  be  definitely  diagnosed, 
which  probably  corresponds  to  what  its  advocates  call  the  "  pretubercu- 
lous state,"  can  undoubtedly  be  strongly  suspected  when,  in  a  patient 
whose  normal  rate  is  known,  there  is  a  })ersistent  or  even  intermittent 
rise  in  rate  which  cannot  be  accounted  for  otherwise. 

That  this  tachycardia,  occurring  so  early,  can  be  explained  on  any 
other  assumption  than  the  action  of  the  poison  of  the  germ  does  not 
seem  possible,  though  it  has  also  been  ascribed  to  atrophy  of  tlie  heart, 
and  while  the  pressure  of  enlarged  bronchial  glands  on  the  vagus  can 
produce  severe  tachycardia,  such  enlargement  is  by  no  means  as  com- 
mon or  as  early  as  is  the  symptom.  It  can  occur  long  before  any  rise 
in  temperature  is  evident.  It  may  at  first  be  paroxysmal  and  brought 
on  by  excitement  or  by  food.  Wells  has  noted  that  the  pulse  of  the 
tuberculous,  unlike  that  of  the  normal  man,  is  not  notably  increased  in 
rate  by  change  of  position  from  lying  down  or  sitting  to  standing,  and 
Papillon  and  other  French  Avritors  have  made  much  of  this  symptom; 
but  the  contrary  is  reported  by  Kuehle  and  Thomayer  ('04),  and  in 
investigating  the  matter  the  writer  has  found  it  as  often  absent  as 
present. 

When  the  disease  becomes  evident  the  pulse  is  almost  always  increased 
in  rapidity,  generally  running  from  85  to  110  in  average  cases,  but  in 
severe  cases  from  110  to  120,  and  at  times  even  higher.  A  persistently 
fast  pulse  of  over  110  is  a  symptom  of  serious  import,  unless  it  yields 
to  rest  and  treatment.  On  the  other  hand,  a  lessening  of  the  pulse-rate 
is  most  encouraging,  and  is  an  excellent  sign  of  lessening  trouble,  with 
decreased  discharge  of  toxins  into  the  blood,  and  speaks  for  increase  of 
vitality  and  recu2:)erative  power;  while  the  persistence  of  a  nearly  nor- 
mal pulse-rate,  despite  demonstrable  lesions,  is  probably  the  best  index 
of  a  robust  constitution  and  good  fighting  power.  In  old  third-stage 
cases  a  rapid  pulse  is  never  absent,  save  toward  the  end,  when  a  slow  pulse 
and  the  appearance  of  intermissions  speak  for  a  failing  heart ;  but  at  this 


SUBJECTIVE   SYMPTOMS  179 

stage  the  tachycardia  is  doubtless  due  largely  to  the  fever.  In  an 
arrested  case  one  cannot  feel  safe  as  to  the  continued  progress  of  the 
patient  as  long  as  the  pulse-rate  remains  high — over  90  in  men  or  95 
in  women;  but  rarely  does  the  pulse  return  entirely  to  its  former  nor- 
mal rate,  however  otherwise  satisfactory  the  results  may  be.  Tachy- 
cardia cannot  be  assumed  to  exist  until  it  has  been  verified  at  many 
different  times,  the  excitement  caused  by  the  physician's  presence  tend- 
ing to  produce  a  temporary  acceleration,  and  when  the  patient  knows 
the  doctor  well,  the  readings  will  differ  from  those  secured  at  first. 

Blood-pressure. — That  there  exists  a  hypotension  of  the  pulse  in  pul- 
monary tuberculosis  is  generally  recognized,  but  there  is  considerable 
difference  of  opinion  as  to  the  time  of  its  first  appearance.  Certain 
authors,  especially  those  of  the  French  school,  believe  it  is  low  in  the 
earliest  stages  of  the  disease,  often  before  any  other  change  can  be 
noted.  This,  however,  is  not  the  general  view,  and  the  writer  has  not 
found  low  pressures  in  his  very  early  cases,  but  it  has  been  in  the  mod- 
erately advanced  cases  that  a  low  blood- j)ressure  is  common. 

Burckhardt  ('OG)  found  hypotension  in  progressive  cases,  whether 
afebrile  or  not,  but  in  nonprogressive  or  afebrile  cases  he  got  normal 
readings.  A  fair  number  of  the  writer's  patients  at  this  stage  have 
shown  a  pressure  of  from  90  to  120  mm.  of  mercury,  and  Teissier  ('05) 
considers  120  to  130  the  usual  figure  in  first-  and  second-stage  cases,  and 
80  to  100  in  third-stage  cases.  Cornet  quotes  Marfan  as  finding  low 
pressure  in  97  out  of  100  cases.  Different  authors  have  different  views 
as  to  Avhat  can  be  considered  a  low  pressure;  any  pressure  under  130  mm. 
is  so  regarded  by  West. 

T.  C.  Janeway,  in  his  recent  work  on  blood-pressure,  quotes  the 
estimates  of  normal  pressure  made  by  various  authors,  using  the  Riva- 
Rocci  apparatus,  which  is  practically  similar  to  Janeway's  and  Stanton's 
sphygmomanometer. 

In  adult  males  Gumprecht  found  an  average  of  140  mm. ;  Hayaski, 
132  mm.;  Heuser,  137  mm.;  and  Thayer,  of  Johns  Hopkins,  in  his 
cases,  between  twenty  and  fifty  years  of  age,  found  139.9  mm.  The 
whole  series  averaging  137  mm.,  with  maxima  and  minima  varying  from 
96  to  180.  Janeway  himself  considers  from  110  to  150  normal.  In 
tuberculosis,  Xaumann,  in  100  cases,  found  a  pressure  over  130  in  69 
per  cent,  over  115  in  13  per  cent,  and  under  115  in  18  per  cent,  and 
considers  115  low  pressure.  Stanton,  in  a  personal  communication,  tells 
me  he  considers  115  low  pressure  in  this  disease,  and  after  considerable 
use  of  his  instrument,  controlled  at  times  by  Janeway's,  I  am  inclined 
to  consider  this  a  fair  estimate;  but  when  formerly  I  used  Gaertner's 
instrument,  which  is  applied  to  the  finger  tips  and  not  to  the  arm,  I 
found  rather  higher  readings.     However,  in  my  early  cases  pressure  has 


180    SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

not  usually  been  low,  and  I  have  been  surprised  to  find  that  pulses 
which  by  the  linger  estimation  seemed  to  have  poor  tension,  would  show 
quite  fair  readings  with  the  instrument. 

In  advanced  cases  low  pressure  is  so  common  that  high  pressure 
should  suggest  renal  changes,  which  should  call  for  investigation  of  the 
urine,  or  a  pulmonary  congestion,  or  an  impending  hemorrhage. 

Teissier  notes  that  high  tension  is  present  in  tuberculosis  tem- 
porarily preceding  hemorrhages  or  acute  congestions,  and  ])ermanently 
in  fibroid  phthisis  with  emphysema,  in  cirrhotic  kidneys,  or  in  diabetic 
tuberculosis,  and  a  gradual  rise  exists  when  the  process  in  the  lungs  is 
lessening  in  intensity  and  a  cure  is  occurring;  or  in  tuberculosis  of 
arthritic  subjects. 

The  low  ])ressure  in  tuberculosis  has  been  asciibed,  like  so  many 
other  symptoms,  to  the  effect  of  the  tubercle  toxin,  as  also  to  a  weak 
heart,  or  to  anemia,  Bouchard  ('05)  having  extracted  a  vasodilator  prin- 
ciple, ectasine,  from  tuberculin.  Just  as  a  lessening  of  tachycardia  has 
a  good  prognostic  meaning,  so  a  rise  of  blood-pressure  and  a  good  ten- 
sion of  the  pulse,  if  the  kidneys  are  sound,  is  almost  as  favorable  a  sign 
as  a  slow  pulse. 

The  heart  presents  few  sym])toms  in  tuberculosis.  Since  Laennec 
first  pointed  it  out,  a  diminution  in  its  size  was,  until  recently,  uni- 
versally admitted,  and  Brehmer  regarded  the  small  heart  as  a  causal 
factor  and  used  it  to  fortify  his  views  as  to  the  etiology  of  the 
disease. 

Louis  long  ago  reported  112  auto}>sies  in  tuberculous  cases,  in  which 
about  fifty  per  cent  showed  unduly  small  hearts  ('04),  and  Kesch  (\)5), 
in  120  cases,  found  altout  the  same  percentage.  Similar  results  have 
been  gotten  by  other  ol)si'rvers. 

In  recent  years,  as  the  result  of  autopsies,  some  have  denied  that 
the  heart  was  small,  Hirsch  furding  it  enlarged  in  forty-four  ])fi-  cent 
and  small  in  but  five  per  cent;  but,  as  he  himself  admits,  in  old  cases 
there  is  a  hypertrophy  and  later  a  dilatation  of  the  right  side,  due  to 
pulmonary  obstruction.  Bouchard  and  Baltazar  ('05),  by  orthodiagra- 
phy, measured  the  heart  in  100  nontuberculous  people,  and  in  100  with 
tuberculosis,  and  in  the  latter,  in  the  first  and  second  stages,  found  the 
heart  smaller  than  normal. 

That  autopsies  should  differ  from  clinical  findings  can  easily  be 
understood  when  we  recall  that  autopsies  are,  with  few  exceptions,  made 
on  advanced  cases  of  tuberculosis  and  on  hospital  material.  In  the  for- 
mer, as  is  well  known,  diminution  of  lung  area  and  fibrosis  place  a 
strain  on  the  lieart  which  results  quite  commonly  in  its  hypertrophy 
and  dilatation.  In  the  latter,  as  a  result  of  alcoholism,  the  kidneys  are 
very  often  cirrhotic.     Thus  autopsies  would  be  a]:)t  to  show  large  hearts 


SUBJECTIVE   SYMI'TOMS  ISl 

where  fluoroscopic  and  otlier  examinations  in  earlier  cases  would  show 
the  reverse. 

As  a  result  of  systematic  percussion  and  mensuration  of  the  heart, 
and  of  fluoroscopic  examinations  in  all  cases,  it  may  be  said  that  in  a 
large  number  of  cases  such  a  small  lieart  will  be  found,  though  whether 
it  is  congenita],  and  to  be  considered  as  a  cause,  or  due  to  atrophy,  and 
to  1)0  regarded  as  an  effect,  cannot  be  stated,  .\nyone  who  will  use  the 
.\-iay  carefully  will  agree  with  this  view. 

Hutchinson  ("Ofi)  has  lately  made  the  interesting  discovery  that  in 
the  animals  at  the  London  Zoological  Gardens,  those  most  prone  to 
tuberculosis  had  hearts  whose  weight  was  less  than  y^  of  their  body 
weight,  while  those  wlio  were  immune  had  hearts  heavier  than  y^^. 
Thus  the  deer,  with  a  heart  -g'g-  its  body  weight,  is  almost  insusceptible, 
while  the  antelope,  with  a  heart  yo^  its  body  weight,  is  very  susceptible 
to  tuberculosis.  The  sheep,  with  a  heart  y^  its  body  weight,  is  rela- 
tively immune ;  the  cow,  whose  great  susceptibility  -is  well  known,  has 
a  heart  only  25-0  of  its  body  weight.  As  a  result  of  a  few  carefully 
made  measurements  on  sanatorium  cases,  he  thinks  he  has  confirmed  his 
views  drawn  from  these  animal  measurements,  finding  the  heart  small 
in  the  majority  of  the  cases,  and  he  has  come  to  consider  a  weak,  under- 
sized heart  as  "  one  of  the  most  constant  and  significant  conditions 
present  in  consum])tion.'* 

Displacement  of  the  heart  in  moderately  or  far-advanced  cases  is 
very  common,  and  is  due  chiefly  to  fibrosis.  It  can  come  on  relatively 
soon,  develops  slowly,  and  can  reach  a  very  pronounced  degree,  the  heart 
often  being  dislocated  completely  into  the  right  side  or  displaced  far 
over  to  the  left.  Such  displacement  is  presumptive  evidence  of  fibrosis, 
and  the  location  of  the  a])ex  should,  therefore,  be  determined  carefully 
in  every  case. 

In  pleurisy  with  effusion,  or  more  especially  in  pneumothorax,  dis- 
placement occurs  rapidly,  can  be  very  marked,  and  may  be  accompanied 
by  circulatory  disturbance  from  bending  of  the  great  vessels  and  trac- 
tion on  the  vagus.  In  a  rapidly  collecting  pleuritic  effusion  purposely 
left  ///  sUn  for  its  pressure  effects,  the  writer  saw  a  severe  and  alarming 
syncopal  attack  from  this  cause  demanding  immediate  relief.  In  left- 
sided  pneumothorax  the  heart  will  show  extreme  degrees  of  dislocation, 
and  the  writer  has  several  times  seen  it  drawn  entirely  into  the  right 
thorax,  though  after  a  while,  unlike  in  fibrosis,  the  heart  in  these  cases 
[lartially  returns  to  the  left. 

Aside  from  pulmonary  stenosis,  whose  causal  relation  to  the  develop- 
ment of  tuberculosis  in  the  lungs  cannot  be  doubted — Meisenburg  ("0"?) 
found  eighty  per  cent  of  all  patients  in  the  Leipzig  clinic  died  of  tuber- 
culosis— valvular  lesions  have  no  relation  to  tuberculosis,  though  retrac- 


182  SYMPTOMATOLOGY   OF   PULMONARY  TUBERCULOSIS 

tions  can  at  times  give  rise  to  various  indefinite  murmurs.  Mitral 
stenosis  was  at  one  time  considered  to  antagonize  tuberculosis,  and 
D.  Eothschild  ('05)  considers  that  it  confers  a  marked  immunity,  and 
that  if  tubei'culosis  develops  on  a  preexisting  heart  lesion,  it  runs  a  mild 
course;  but  this  is  contrary'  to  the  writer's  experience,  and  Norris  ('04), 
in  an  excellent  paper  on  tlie  heart  in  tuberculosis,  says:  "In  view  of 
the  frequency  with  which  tuberculosis  of  the  lung  has  been  found  asso- 
ciated with  valvuhar  heart  disease,  we  are  forced  to  conclude  that  the 
latter  exerts,  if  any,  but  very  slight  influence  on  the  former,  either  as 
an  inhibitive  or  curative  influence,  even  if  satisfactory  compensation  is 
maintained." 

Hypertropb}^  and  dilatation  of  the  right  side  of  the  boart,  owing  to 
resistance  in  the  lesser  circulation  in  the  lung  from  obliteration  of  so 
many  blood-vessels,  is  seen  in  some  cases  of  extensive  tuberculosis,  being 
})resent  in  4G  out  of  1,276  cases  (Phi])ps  Institute  Histories).  Such 
a  condition  may  ojiiite  frequently  be  demonstrated  by  the  fluoroscope 
when  other  metliods  fail  to  reveal  it. 

A  subclavian  murnmr  (see  auscultation),  due  to  kinking  of  the 
artery  by  apical  contractions,  is  not  uncommon,  but  has  not  the  diag- 
nostic value  ascribed  to  it  b}'  Euehle,  as  it  has  been  shown  that  it 
can  occur  in  other  conditions. 

Accentuation  of  the  pulmonic  second  sound,  with  or  without  redupli- 
cation, is  very  commonly  found,  but  is  not  of  diagnostic  value.  The 
same  ma}^  be  said  of  a  roughening  of  the  tricus])id  systolic  sound,  which 
the  writer  has  noted  in  a  large  percentage  of  his  cases. 

Pericardial  frictions  are  at  times  found,  but  tuberculous  pericarditis 
is  usually  overlooked,  and  is  found  more  commonly  at  tlie  autopsy  table 
than  by  the  bedside.  Systolic  retraction  of  one  or  other  of  the  left  inter- 
spaces, commonly  the  second,  near  the  sternum,  is  often  seen  in  eases 
with  emaciated  chests,  and,  as  Euehle  points  out,  is  due  simply  to 
air  pressure  on  the  thin,  wide  interspaces,  and  should  l)e  distinguished 
from  retractions  occurring  at  tlie  apex  of  the  heart  as  the  result  of 
pericard ial  synochia\ 

Digestive  System. — On  the  integrity  of  the  digestive  system  in  tuber- 
culosis generally  depends  the  result  of  the  conflict,  and  he  wlio  treats 
tuberculosis  very  soon  learns  to  study  its  symptoms  with  especial  care.  On 
it,  more  tlian  on  any  other  part  of  the  body,  depends  the  outlook  of  the 
patient  for  recovery,  for  unless  a  proper  amount  of  nourislunent,  prop- 
erly prepared  by  it,  is  given  to  the  cells,  they  will  surely  fail  in  their 
battle  with  tlie  disease.  From  the  moment  the  food  enters  the  mouth, 
until  its  useless  residue  is  thrown  off,  each  step  of  the  digestive  act  is 
of  tlie  utmost  importance,  hence  every  part  of  the  alimentary  tract 
should  be  most  carefully  watched  to  see  that  it  functionates  properly. 


SUBJECTIVE   SYMPTOMS  183 

The  mouth  in  early  cases  presents  no  symptoms  of  value,  unless 
we  accept  the  views  of  Fredericq,  Thompson,  and  others,  to  which  G. 
Sticker,  in  1888,  drew  attention.  He  described  a  sliar])ly  marked  red 
line  at  tlie  border  of  the  gums,  especially  of  the  incisor  teetli.  While 
this  line  is  present  in  some  tuberculous  cases,  it  is  also  found  in  other 
conditions,  and  in  tuberculosis  it  is  found  chiefly  in  advanced  cases  and 
rarely  in  incipient  ones.     It  is  not  a  sign  of  value. 

The  tongue  in  early  cases  shows  no  alterations  which  can  be  con- 
nected with  tlie  disease,  though  wliere  digestive  disturbances  are  present 
it  is  apt  to  be  slightly  coated.  ■  Tlie  frequency  of  dyspepsia  in  moderately 
advanced  cases  accounts  for  the  frequency  of  a  coated  tongue  in  such 
cases,  while  in  advanced  cases  there  is  very  frequently  found  the  red, 
shiny  tongue  of  all  chronic  cachexias. 

The  condition  of  tlie  teeth  in  pulmonary  tuborculo?is  should  always 
be  carefully  looked  into,  as  the  bad  effect  of  cai'ies  on  digestion  is  well 
known,  and  in  advanced  cases  such  caries  is  unduly  common  and  gives 
much  trouljle.  In  those  in  whom  we  find  what  has  been  called  the 
tuI)erculous  constitution  the  teeth  are  apt  to  be  unduly  transparent  and 
delicate,  probably  from  a  deficiency  of  lime  salts,  and  not  infrequently 
transverse  ridges  are  present,  which,  like  the  transverse  white  marks  on 
the  nails,  probably  correspond  with  periods  of  lowered  vitality. 

The  jjhaiijnx  shows  chronic  pharyngitis,  with  undue  prevalence  of 
adenoid  tissue  on  the  posterior  and  lateral  pharyngeal  walls,  which  often 
are  studded  all  over  with  the  small  lymphoid  masses  of  follicular 
phar}Tigitis.  Extreme  pallor  of  the  hard  and  soft  palate  and  posterior 
pharyngeal  wall  and  epiglottis  is  common  in  old  cases. 

Follicular  pharyngitis  is  very  common  and  develops  in  old  severe 
cases  into  pharyngitis  sicca,  which  can  cause  considerable  inconvenience, 
while  thrush  and  aphthous  stomatitis  are  at  times  troublesome  in  the 
last  stage.  Bohr  found  twenty-five  per  cent  of  chronic  granular,  or 
dry  cases  of  pharyngitis. 

Tuberculous  pharyngitis  is  fortunately  very  rare,  for  it  is  excessively 
painful  and  its  course  is  uniformly  fatal.  It  occurs,  according  to  the 
classification  of  Barth  ('80),  who  has  written  a  very  complete  mono- 
graph on  the  subject,  in  three  forms:  (1)  An  acute  tuberculous  follicu- 
litis, (2)  a  diffuse  miliary  tuberculosis,  and  (3)  a  chronic;  ulcerous 
tuberculosis.  It  begins  with  pain  and  the  appearance  of  isolated  or 
confluent  whitish-yellow  elevations,  rapidly  spreading  and  coalescing 
into  ])latelike  masses,  hard  to  the  touch  and  with  little  or  no  inflamma- 
tory areola.  The  pain  in  the  throat  becomes  lancinating  and  ])urning, 
and  does  not  remit.  Dysphagia  ai)pears,  and  there  is  troublesome  saliva- 
tion and  pain  running  into  the  ears.  In  a  very  marked  case,  in  which 
death  occurred  before  ulceration  took  ])lace,  the  tubercles  s])read  u])  the 


184  SYMPTOMATOLOGY   OF   PULMONARY   TriJERCTiLOBLS 

posterior  pliar3ngeal  wall,  and  from  the  soft  to  the  hard  palate  with 
surprising  rapidity,  each  day  showing  a  distinct  advance,  while  the  pain 
was  excessive  and  scarcely  affected  Ijy  anodynes,  ff  tlie  patients  live 
long  enough,  ulcers  form  and  spread  rapidly. 

The  tonsils,  while  frequently  enlarged,  Behr  ('05)  finding  ahnormal 
tonsils  in  sixteen  per  cent  of  cases,  show  no  special  ocular  changes. 
TTypcrtrojihy  of  the  lingual  tonsil,  while  not  more  common  in  tubercu- 
losis than  in  otlier  conditions,  is  more  troublesome,  as  it  often  causes 
an  obstinate  hard  cough  hy  pressure  on  tlie  epiglottis,  disappearing  on 
the  removal  of  this  pressure. 

The  stomach  presents  marked  alterations  from  tlie  normal.  A  large 
number  of  cases  of  pulmonary  tuberculosis  begin  as  a  dyspepsia,  and 
few  fail  sooner  or  later  to  show  some  evidence  of  gastric  "disorder. 
Janowski  ('07)  found  gastric  disturbance  in  fourteen  per  cent  of  700 
incipient  cases,  and  eight  per  cent  of  gastric  and  intestinal  disturbances. 

Many  patients  report  themselves  as  having  always  been  poor  or  fickle 
eaters,  and  Behring  ('04)  regards  this  lack  of  good  appetite  as  an  early 
symptom  of  the  presence  of  tuberculosis  in  the  system.  It  could  usually 
be  considered  rather  as  an  excellent  predisposing  cause  through  its 
depressing  effect  on  the  general  nutrition. 

In  incipient  cases  we  find  ver}^  commonly  loss  of  appetite  in  a  mod- 
erate, but  not  at  this  time  in  an  extreme,  degree,  a  sense  of  discomfort, 
fullness  and  Aveight  after  eating,  belching,  pain,  signs  of  motor  insuffi- 
ciency and  hyperacidity.  Fox  ('91)  quotes  Fenwick,  who  found  hyper- 
acidity in  fifty-six  per  cent  of  200  cases.  Pasquier  ('03)  found  hyper- 
chlorhydria  in  sixty-nine  per  cent  of  his  incipient  cases  and  in  fifty-seven 
per  cent  of  his  second-stage  cases. 

Vomiting  after  meals,  which  Grancher  and  Barbier  ('97)  and  Fox 
('91)  regard  as  a  very  early  symptom,  was  not  found  in  the  writer's 
early  cases,  which  agrees  with  Janowski  ('07),  who  foimd  it  rare,  though 
it  is  quite  common  in  somewhat  more  advanced  cases,  being  usually 
excited  by  the  cough  whicli  eating  is  so  apt  to  produce,  but  at  times 
by  the  effort  to  bring  up  very  tenacious  sputum.  It  can  be  very  obsti- 
nate, and  coming  on  after  meals  may  at  times  seriously  affect  the  nutri- 
tion. Tenderness  in  the  pit  of  the  stomach  on  pressure,  or  pain  appear- 
ing after  eating,  those  common  accompaniments  of  hyperacidity  are 
frequently  seen. 

Fermentative  dyspepsia  is  a  very  common  complaint  with  tuber- 
culous patients,  and  is  often  seen  very  early.  The  taking  of  food  is 
shortly  followed  by  a  sen.se  of  fullness  and  distention  with  belching,  and 
few  of  the  lesser  symptoms  are  so  hard  to  remove. 

The  frequency  in  tuberculosis  of  those  sequelfe  of  motor  insufficiency, 
dilatation,  and  dislocation,  has  not  been  sufficiently  recognized.  ]\rarfan 


SLfBJECTlVE   SYMPTOMS  185 

alone  laying  slross  on  ii.  11'  the  .stomach  is  niapijed  out  in  all  ca>es, 
dilatation  will  be  I'onnd  in  a  large  percentage  of  the  moderately  ad- 
vanced cases,  and  in  some  of  the  early  cases  dilatation,  often  of  an 
extreme  degree,  at  times  accompanied  by  dislocation.  In  view  of  the 
importance  of  perfect  digestion  in  tuberculosis,  we  should,  therefore, 
never  omit  from  our  physical  examination  a  mapping  out  of  the  stomach. 

In  advanced  cases  there  are  present  the  signs  of  chronic  atrophic 
gastritis,  a  severe  and  often  absolute  anorexia,  a  disgust  for  food  so 
great  that  tiie  very  sight  of  a  meal  induces  vomiting,  hyperacidity, 
and  absence  of  heartburn.  Pasquier  ('03)  found  hypochlorhydria  in 
seventy-six  per  cent  of  his  advanced  cases.  Digestion  is,  moreover,  fur- 
ther hindered  by  the  effect  of  the  high  fever,  and,  as  has  been  noted 
in  discussing  anorexia,  the  chief  meals  must,  therefore,  be  taken  at  the 
periods  of  lowest  temperature. 

Since  the  progress  of  the  case  depends  so  largely  on  a  proper  func- 
tioning of  the  stouiach,  it  is  evident  that  in  future  more  and  more 
attention  will  be  paid  to  analyses  of  gastric  secretion  in  tuberculous 
patients,  and  their  diet  will  be  regulated  accordingly.  When  this  is 
done  we  shall  get  better  results  than  ever  before. 

The  Intestinal  Canxil. — In  early  or  in  moderately  advanced  cases 
constipation  is  surprisingly  common,  and  cathartics  are  frequently 
needed.  While  this  may  in  part  be  explained  by  the  limitation  of 
exercise  in  the  beginning  of  a  rest  cure,  this  cannot  explain  the  undue 
frequency  of  this  trouble  in  the  tuberculous,  and  it  must  have  some 
connection  with  the  presence  of  the  germ  in  the  body. 

Autopsies  demonstrate  intestinal  lesions  in  a  large  number  of  cases, 
Heinze,  reported  by  Miiller  ('01),  finding  them  in  630  out  of  l,22(i 
cases  of  pulmonary  tuberculosis;  Janowski  ('07)  found  13  per  cent  of 
intestinal  symptoms  in  700  incipient  cases  and  8  per  cent  combined 
gastric  and  intestinal ;  Fenwick  and  Dodwell,  in  500  out  of  883 ;  Eisen- 
hart  in  556  out  of  1,000.  From  these  statistics  it  would  be  natural  to 
suppose  that  diarrhea  and  intestinal  pain  would  be  prominent  in  the 
disease,  but,  strange  to  say,  this  is  not  the  case,  and  even  where  after 
death  extensive  ulceration  has  been  found,  often  there  will  not,  during 
life,  have  been  the  least  intestinal  disturbance.  Fox  ("91)  found  diar- 
rhea in  72  acute  cases  where  ulceration  was  present,  only  36  times,  and 
in  36  chronic  cases  he  found  66  per  cent  of  ulcers  and  -11  per  cent  of 
diarrhea. 

In  the  beginning  tin  it  aic  no  intestinal  symploms.  unless  we  so  con- 
sider the  nuirked  tendency  to  constipation  already  noted,  the  dyspepsia 
at  this  stage  being  chiefly  gastric.  The  diarrhea  which  Fox  considers 
at  times  an  early  symptom  has  not  been  presenl  in  Ibc  wriU'r's  early 
cases.      Fo\    believes    tbal    tboro    is   an    irriJablc   coiKlitidii    nf   tlic   lowei' 


186  SYMPTOMATOLOGY  OF   PULMONARY  TUBERCULOSIS 

bowel  and  undue  liability  to  diarrhea  on  slight  provocation,  such  as 
slight  dietary  errors,  chilling,  or  hot  weather,  and  due  to  a  catarrhal 
inflammation  of  the  mucous  membrane.  Cornet  also  considers  it  an 
early  symptom,  and  ascribes  it  to  the  swallowing  of  sputum,  the  mucous 
membrane  being  irritated  by  the  proteins  of  the  bacillus,  or  else  to  the 
effect  of  the  absorption  by  the  Ijlood  of  large  amounts  of  toxin,  but 
early  cases  do  not  have  large  amounts  of  sputum,  and  undeniable  as 
are  the  remote  effects  of  the  tubercle  toxins  on  which  Cornet  so  fre- 
quently insists,  it  would  seem  improbable  that  they  are  present  in  large 
amounts  in  incipient  cases.  In  moderately  advanced  cases  there  is  very 
frecjuently  flatulence  and  intestinal  indigestion,  which  can  at  times  be 
very  troublesome,  and  in  this  stage  also  we  will  find,  though  not  often, 
an  obstinate  diarrhea  due  to  catarrhal  colitis,  which  may  simulate  a 
tu bercu 1 ou s  d i a r rh ea . 

However,  it  is  usually  only  in  the  third  stage  that  the  intestinal 
canal  gives  much  trouble,  and  diarrhea  is  at  this  time  much  more  com- 
mon. Fox's  statement  that  fifty  per  cent  of  old  cases  have  diarrhea 
is  correct,  if  dealing  with  patients  of  all  social  classes,  but  it  must 
be  remembered  that  this  will  vary  according  as  the  patients  are  hos- 
pital or  private  patients,  the  careless  habits  and  poor  hygiene  of  the 
former  in  their  past  life,  and  the  generally  unfavorable  conditions 
under  which  they  have  lived,  rendering  them  more  liable  to  the  severe 
manifestations  of  the  disease  than  the  more  carefully  nurtured  patients 
one  generally  sees  in  ])rivate  practice. 

Tuberculous  diarrhea  is  due  either  to  ulceration  of  the  bowels, 
or,  less  commonly,  to  amyloid  change,  but  Fox,  and  more  recently 
J.  Walsh  ("06),  consider  that  the  nephritis  of  late  tuberculosis  may 
account  for  some  cases.  It  is  wise  to  be  guarded  in  a  diagnosis  of  amy- 
loid diarrhea,  which  cannot  be  made  safely  unless  changes  in  the  liver 
and  spleen  and  albumin  in  the  urine  and  polyuria  are  found.  Williams 
('87)  would  differentiate  the  amyloid  from  the  ulcerous  diarrhea  by  the 
fact  that  the  former  is  not  very  profuse,  is  watery,  and  has  some  corre- 
spondence with  the  sweats,  lessening  when  these  are  profuse.  There 
is  no  tenderness  of  the  bowels,  the  tongue  is  more  furred  than  red  and 
raw,  as  in  the  ulcerous  form,  and  the  liver  and  spleen  are  enlarged. 

The  majority  of  diarrheas  in  the  third  stage  can  safely  be  ascribed 
to  tuberculous  ulcers,  but  a  positive  diagnosis  is  almost  impossible,  the 
presence  of  bacilli  in  the  stools  being  rendered  valueless  by  the  impos- 
sibility of  excluding  the  swallowing  of  sputum.  The  stools  of  such  a 
diarrhea  are  apt  to  be  unusually  fetid  and  slimy  and  contain  pus,  and 
at  times  are  streaked  with  blood.  Louis,  quoted  by  Eenzi  ('94),  con- 
sidered a  diagnosis  of  tuberculous  ulceration  justified  when  a  tubercu- 
lous patient  suffered  more  than  six  weeks  with  a  continuous  diarrhea, 


SUBJECTIVE   SYMFrOMS  187 

and  Traube  thought  such  a  diagnosis  safe  in  the  presence  of  persistent 
and  active  diarrhea  if  dietary  errors  and  amyloid  change  could  be  ex- 
cluded and  the  stools  were  colicky  and  bloody.  The  combination  of 
colicky  pains  coming  on  shortly  after  taking  food,  pain  on  palpation, 
ravenous  appetite,  rapid  emaciation,  and  pus  in  the  stools,  point  with 
practical  certainty  to  a  tuberculous  ulcerative  enteritis,  and  the  appear- 
ance in  a  tuberculous  patient  of  obstinate  colicky  pains  after  meals 
should  excite  suspicion. 

Intestinal  hemorrhages  are  much  less  common  than  in  typhoid,  and 
intestinal  perforation  is  still  rarer,  Eisenhardt  giving  the  frequency  of 
the  latter  as  five  per  cent  of  all  cases  of  intestinal  tuberculosis;  Fen- 
wick  and  Dodwell,  ten  per  cent.  Unlike  the  perforations  occurring  in 
more  acute  diseases,  they  may  produce  few  or  no  symptoms,  and  appar- 
ently not  infrequently  heal  spontaneously. 

Two  rare  forms  of  intestinal  tuberculosis  are  the  hypertrophic  and 
the  stenotic.  Tlie  former  is  described  by  Mathieu  ('04)  as  being  char- 
acterized by  hypertrophy  of  the  cecum  and  ileocecal  region  of  the  bowel, 
coming  on  gradually  in  cases  of  very  chronic  course.  There  is  dull 
pain  in  the  right  iliac  fossa,  with  attacks  of  colic  and  diarrhea  with 
vomiting.  Slowly  there  develops  a  sausagelike  mass  in  the  cecal  region 
with  signs  of  chronic  stenosis.  The  stenotic  form  is  due  to  scar  forma- 
tion in  the  circular  ulcers,  and  is  confined  to  the  lower  third  of  the 
small  intestines.  It  is  commonest  in  fibroid  cases,  and  often  there  are 
no  pulmonary  symptoms  at  all,  so  that  these  cases  are  apt  to  be  mis- 
taken for  cases  of  syphilitic  stenosis.  They  are,  as  a  rule,  very  gradual 
in  their  development,  and,  as  the  constrictions  are  located  in  the  small 
intestine,  constipation  is  usually  absent.  The  chief  symptoms  are 
periodic  and  increasingly  severe  colicky  attacks,  generally  accompanied 
by  vomiting,  during  which,  in  emaciated  patients,  the  distended  coils 
of  the  intestines  can  be  seen  to  move  under  the  thin  abdominal  wall, 
and  the  gurgling  of  gas  can  be  heard. 

Tuberculous  peritonitis  is,  strictly  speaking,  a  complication.  Buschke 
found  it  in  1G.5  per  cent  of  1,3^3  autopsies.  While  a  peritonitis  can 
occur  acutely  as  the  result  of  the  perforation  of  an  ulcer,  or  by  exten- 
sion of  inflammation  through  the  peritoneum  covering  the  base  of  a 
deep  ulcer,  this,  of  course,  is  not  a  real  tuberculous  peritonitis. 

Chronic  tuberculous  peritonitis  generally  comes  on  insidiously,  with 
tlie  collection  of  fluid  in  the  alxloinen  and  a  gradual  development  of 
tympanitic  distention.  However,  the  fluid  is  often  encapsulated,  and 
thus  may  not  be  demonstrable,  while  at  times  there  is  no  fluid  at  all. 
Pain  is  usually  present,  but  is  rarely  severe,  and  generally  there  is  only 
a  sense  of  abdominal  distress.  The  temperature  is  variable,  often  being 
absent   for  some  part  of   the  time.      Palpation   of  the   abdomen   will 


INS  SYMPTOMATOLOGY   OF    PULMONARY   TUBERCILOSIS 

demonstrak'  tiimoiiike  masses  produced  by  the  adliesion  oi'  the  coils  of 
intestine,  but  this  may  not  be  discoverable  if  there  is  much  distention. 
In  some  cases  if  the  peritoneum  is  richly  studded  with  tubercles,  pal- 
pation gives  a  crepitus. 

The  Liver. — The  liver  does  not  present  any  symptoms,  but  signs  of 
imperfect  liver  function  in  patients  who  are  practicing  hyperalimenta- 
tion are  common,  and  while  most  of  the  so-called  "  bilious  attacks  " 
which  are  then  so  frequent  are  probably  due  to  gastroduodeual  catarrh, 
il  is  reasonal)le  to  su|)i)ose  that  the  liver,  as  well  as  the  stomach  and 
Ijowels,  are  deranged.  UUom  ('06),  while  finding  liver  tuberculosis  in 
a  hirge  percentage  of  cases  at  autopsy,  found  its  clinical  recognition 
impossible.  In  nearly  every  case  he  also  found  passive  congestion  of 
the  liver,  but  his  material  consisted  of  advanced  cases  in  the  very  poor, 
and  doubtless  examinations  in  earlier  cases,  if  possible,  would  show 
othei'  results. 

Urinary  System. — While  the  kidneys  are  affected  in  a  large  number 
of  cases,  the  symptoms  are  usually  not  marked  and  are  more  often  over- 
looked. In  incipient  cases  the  bladder  and  kidneys  are  usually  normal, 
altliough  Papillon  ('97)  and  Eobin  ('!>7)  speak  of  frequent  micturition 
and  polyuria  as  early  symptoms.  The  urine  is  usually  negative  in  the 
beginning  of  the  disease,  but  later  on,  if  carefully  studied  quantitatively, 
can  give  valuable  evidence  of  the  tissue  waste  that  is  occurring,  and 
French  authors  consider  that  a  demineralization  of  the  system  is  shown 
by  the  excess  of  earthy  phosphate  in  the  urine,  although  Ott  ('03)  does 
not  corroborate  this.  Croftan  ('03)  found  an  excess  of  calcium  ex- 
cretion. 

This  phosphaturia  is  considered  by  ({rancher  ('97)  an  evidence  of 
cell  destruction,  and  what  he  says  is  so  suggestive  that  it  is  well  to  quote 
from  him  at  length : 

The  pecviliar  demineralization  of  the  tuberculous  from  this  point  of 
view  is  worthy  of  great  attention  by  all  observers.  It  shows  that  uncom- 
plicated tuberculous  consumption  follows  special  laws,  and  that  its 
mechanism  does  not  resemble  that,  for  example,  of  diabetic  consumption. 
The  low  content  of  the  urine  in  sulphur,  the  considerable  increase  of 
phosphates,  combined  with  the  nitrogenous  derivatives  of  insufficiently 
hydrated  albuminous  substances,  indicate  a  destruction  bearing  especially 
upon  the  phosphorized  albuminoids,  nucleo-albumins,  and  nucleins.  These 
bodies  exist  only  in  the  cells  and  especially  in  the  white  cells.  .  .  .  From 
the  first  the  tuberculous  utilize,  as  we  have  seen,  against  the  bacillus,  the 
polynuclear  leucocytes,  and  then  the  mononuclear.  The  destruction  {con- 
fiommafion)  of  these  elements  is  in  direct  proportion  to  the  iiroduction  of 
toxins.  The  necessity  for  the  tuberculous  to  meet  this  waste  of  leuco- 
cytes is  shown  by  the  special  activity  of  the  bone  marrow  which  one  sees 
in    the    1  ubcrculous,    or    which    one    ean    produce    experimentally   by    the 


SUBJECTIVE   SYMPTOMS  ISO 

iuoculatiou  of  tuberruliu  <>r  the  rormation  at  a  distance  of  a  local  tuber- 
<ulous  focus.  To  meet  this  excessive  waste  of  phosphorus  and  of  nitro 
^,'fiiized  substances,  the  fofmativc  cells  of  the  marrow  Ixtrrow  their  jjhos- 
phorus  from  the  bones;  as  for  the  proteid  substances,  they  can  only  get 
it  from  the  food,  and  for  lack  of  that  from  the  lleshy  reserves  of  the 
org'anism,  especially  the  muscles.  .  .  .  The  appearance  in  the  urine  of  the 
tuberculous,  along  with  an  excess  of  phosphorus,  of  those  products  of 
disassimilation  of  nucleins,  xanthin,  hypoxanthin,  and  uric  acid,  is  a 
proof  of  this  especial  disassimilation.  The  practical  result  of  what  pre- 
cedes is  that  the  tuberculous  have  need  of  great  quantities  of  leucocytes, 
because  around  new  lesions  many  are  destroyed.  .  .  .  The  loss  of  phos- 
phates in  the  urine  gives  the  measure  of  the  destruction  of  leucocytes — 
that  is  to  say,  of  the  importance  of  the  phenomena  of  the  struggle  which 
is  occurring  in  the  tuberculous  foci,  and  at  the  same  time  it  also  gives 
the  measure  of  the  production  of  leucocytes — that  is  to  say,  of  the 
resources  of  the  body.  The  variations  of  demineralization  can  therefore, 
according  to  the  circumstances,  have  a  favorable  or  unfavorable  meaning 
to  the  doctor.  If  the  phosphates  lessen  while  the  general  condition  is 
improving,  it  would  indicate  that  cellular  destruction  is  less  active,  that 
the  tuberculous  process  is  dying  out;  if  they  diminish  in  the  presence  of 
emaciation  and  aggravation  of  the  symptoms,  it  shows  that  the  organism 
is  becoming  exhausted  and  that  the  means  of  defense — the  formation  of 
leucocytes — is  weakening. 

De  Roiizi  also  notes  that  one  can  often  find  a  direct  relation  be- 
tween excretion  of  earthy  pliosphates  and  the  emaciation,  and  that  the 
lime  salts  are  increased  in  early  cases  and  lessened  in  late  ones. 

Alhitniinurid,  while  at  times  present  in  incipient  cases,  is  not  more 
frecpient  than  in  the  nontnhercnlous,  but  in  advanced  cases  it  is  very 
common,  .7.  Walsh  finding  it  in  -17  per  cent  of  his  old  cases,  Fox 
in  '.\2  per  cent  of  his  chronic  cases  and  8  per  cent  of  his  acute  cases. 
Montgomery  ('()())  was  able  usually  to  find  it,  though  in  very  small 
amounts.  Cornet  considers  it  an  evidence  of  tuberculosis  of  the  urinary 
tract,  hut  in  view  of  the  frequency  of  nontuberculous  nephritis  in  this 
disease,  it,  would  not  be  safe  to  base  a  diagnosis  of  tubea-ulous  kidney  on 
it.  Fox  considers  it  due  to  amyloid  kidney,  but  certainly  amyloid 
kidney  is  far  less  common  in  this  disease  than  is  albuminuria.  Senatoi- 
[Hi'))  considers  it  often  (he  result  of  a  chronic  parenchymatous  ne- 
phritis, which  he  considers,  in  Berlin,  to  be  most  commonly  due  to 
tuberculosis,  and  J.  Walsh  considers  this  form  of  ne])hritis  to  he  the 
typical  nephritis  of  tuberculosis,  having  found  it  in  30  per  cent  of 
his  cases.  Midler,  however,  considers  granular  kidney  the  typical 
tuI)erculous  kidney,  quoting  Landouzy  and  Bernard  to  the  same  etfect. 
West  ('02)  considers  gi'anular  kidney  not  connected  in  any  way  with 
tuberculosis. 


190    SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

The  relative  frequenc}'  of  a  chronic  nephritis  in  old  tuberculosis, 
and  the  fact  that  tuberculous  nephritis  often  runs  a  symptomless  course, 
should  cause  us  to  examine  the  urine  of  all  second-  and  third-stage  cases 
for  albumin,  for  uremic  coma  is  not  an  unknown  ending  to  tuberculosis 
and  may  come  as  a  disagreealjle  surprise. 

Ehrlich's  diazo-reaction,  at  one  time  hailed  as  a  diagnostic  measure 
of  great  value,  has  lost  all  claims  to  such  a  title  since  it  has  been 
found  in  typhoid,  measles,  and  other  diseases.  Prognostically,  Holm- 
gren, of  Stockholm  (OG),  considers  it  of  the  greatest  value,  but  while 
if  persistently  and  intensely  present  a  bad  prognosis  is  justified,  its 
absence  cannot  Ije  considered  a  good  omen,  for  it  can  be  absent  in  severe 
cases,  and  it  is  occasionally  transiently  present  in  early  and  favorable 
cases.  A.  Williams  ('07)  reports  that  in  negroes,  however  severe  the 
case,  he  never  found  the  reaction,  though  it  was  present  in  the  majority 
of  his  severe  cases  occurring  in  whites.  It  must  be  recalled,  in  a  study 
of  the  diazo-reaction.  that  a  most  careful  and  accurate  technic  is  neces- 
sary, and  that  great  variations  in  results  can  be  produced  by  the  indi- 
vidual interpretation  of  border-line  reactions  by  different  observers. 
The  presence  of  albumose  in  the  urine,  which  has  been  dwelt  upon  espe- 
cially by  Krehl,  Matthes,  and  Schultess,  has  been  suggested  by  Ott  as 
a  means  for  deciding  whether  temperature  following  on  exercise  is 
harmful,  and  such  exercise,  therefore,  contraindicated  or  not.  If  albu- 
mose appears  in  the  urine  he  considers  rest  necessary,  but  in  its  absence 
does  not  consider  temperature  an  absolute  contraindication  to  exercise. 
Webb,  of  Colorado  Springs,  has  reported  success  in  using  this  method 
of  control. 

Renal  iuhrrculosis  can  advance  to  a  considerable  extent  before  it 
manifests  itself  by  symptoms.  These  symptoms  are  discomfort^  weight, 
and  pain  in  the  lumbar  region,  pain  on  palpation,  and  frequent  and 
painful  micturition.  Blood  appears  early  in  the  urine,  generally  in 
small  amounts,  but  at  times  in  larger  quantities,  but  does  not  recur 
frequently,  a  point  which  Fox  uses  in  distinguishing  it  from  the  hema- 
turia of  renal  cancer.  The  urine,  which  is  always  acid  and  contains 
albumin,  shows  liacilli,  chiefly  found  in  bundles  and  sheaves.  Ninety 
per  cent  of  Walsh's  cases,  which  were  advanced  ones,  showed  bacilli. 

When  scanty  and  isolated  they  must  be  differentiated  from  smegma 
bacilli,  first  by  great  care  in  collecting  the  specimen  by  catheter,  and 
second  by  differential  decolorization.  Smegma  bacilli,  like  tubercle 
bacilli,  are  not  decolorized  by  five  per  cent  watery  sulphuric  acid,  but 
unlike  these  yield  up  their  stain  in  three  per  cent  hydrochloric  acid 
alcohol.  Along  with  these  s}Tnptoms  there  are  often  symptoms  of  tuber- 
culosis of  the  bladder,  testicle,  epididymis,  vas,  or  seminal  vesicles,  and 
any  suspicious  urinary  symptoms  should  cause  us   to   examine  these 


SUBJECTIVE   SYMPTOMS  191 

organs.  The  rise  of  temperature  is  slight  and  apt  to  he  intermittent, 
the  general  condition  very  good  for  long  periods. 

The  Generative  System. — The  old  question  as  to  whether  the  sexual 
desire  is  increased  or  diminished  in  the  tuberculous  is  one  which,  by  its 
very  nature,  and  by  the  unwillingness  of  female  patients,  at  least,  to  give 
information,  cannot  be  settled  by  clinical  observation.  A'arious  men 
will  form  various  opinions,  largely  according  to  the  class  of  patients 
they  observe  and  tlieir  own  mental  attitude.  The  general  impression 
of  clinicians  has  been  that  the  tuberculous  patient  shows  an  excessive 
sexual  passion,  and  various  examples  of  sexual  life  carried  on  actively 
until  very  shortly  before  death  have  been  reported,  but  in  so  far  as 
observation  in  practice  has  been  able  to  inform  him  in  this  matter,  the 
writer  has  not  noted  any  increase  that  was  not  natural  to  people  Avho 
are  being  highly  fed,  who  exercise  hut  moderately,  and  are  thrown  into 
intimate  intercourse  day  after  day,  and  under  such  conditions  many  a 
male  patient  is  apt  to  become  unduly  alive  to  the  charms  of  his  female 
copatients  and  to  allow  his  idle  imagination  too  much  scope.  Cassaet 
thinks  tuberculous  women  more  excitable  than  men,  but  such  a  state- 
ment would  he  very  hard  to  substantiate.  Louis,  with  a  very  large 
experience  among  Frenchmen,  thought  that  in  advanced  cases  the 
sexual  passion  was  impaired.  That  intercourse  has  a  harmful  effect 
on  most  patients  is  frequently  noted,  the  visits  of  huslvands  to  wives, 
or  vice  versa,  too  often  lieing  followed  by  rise  of  temperature  and 
aggravation  of  sjinptoms.  Moreover,  intercourse  shows  its  harmful 
effects  directly  at  times  ])y  causing  pain  in  the  diseased  lung  and  in- 
crease of  cough,  indicating  that  it  probably  has  some  local  congestive 
effect. 

Mmstrval  irrrgnlarHies  in  women  are  common  and  are  of  two  sorts, 
a  missing  of  the  menstrual  period  in  the  incipiency  of  the  trouble, 
chiefly  in  young  girls,  and  which  passes  off  as  they  improve,  and  in  old 
cases  an  al)Solutc  cessation  of  the  menses.  In  the  former  its  reestab- 
lishment  shows  increasing  vitality,  and  of  course  is  a  good  sign,  but 
in  late  cases  it  is  rarely  reestablished,  and  as  a.  drain  on  the  system  is 
thus  saved  it  is  not  desiral)lo  that  it  should  be.  At  the  time  of  the 
menses  hemorrhages  are  unduly  common,  and  attacks  of  pvdmonary 
congestion  are  much  more  apt  to  occur  at  such  times  in  women  than 
at  any  other,  so  that  the  doctor  learns  to  dread  them.  The  effect  of 
the  menses  on  the  temperature  has  already  been  noted  under  Fever. 
The  rise  generally  begins  the  day  before  the  flow  sets  in  and  lasts  until 
it  is  well  oslahlislied. 

The  Bones  and  Muscles. — The  osseous  system  gives  rise  to  no 
symptoms  in  pulmonary  tuberculosis.  The  muscles  show  wasting, 
both   generally   and,  before   general   wasting  appears,   locally   over   the 


192    SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

site  of  tljf'  j)ulniouai-y  trouble,  this  latter  being  in  part  responsible 
for  the  flattening^  of  the  iippei'  Hiorax  seen  on  inspection  in  the 
earlier  eases. 

The  local  eonlraelion  of  the  muscles  on  percussion,  called  niyoidema, 
and  described  first  by  Stokes  ("82),  has  been  raised  to  the  dignity  of  a 
symptom  by  some  authors,  but,  as  Stokes  said,  there  is  nothing  in  this 
muscular  irritability  peculiar  to  phthisis.  It  will  be  found  in  many 
wasting  diseases,  and  it  would  be  rash  to  try  to  strengthen  a  doubtful 
diagnosis  by  it. 

The  Skin. — A  considerable  number  of  patients  have,  and  have 
had  for  years  previous  to  their  sickness,  a  delicate,  transparent  skin, 
through  which  the  blue  veins  show,  and  which  flushes  easily  and  quickly, 
as  well  as  fine,  silky  hair.  While  this  speaks  for  a  poor  resisting  power, 
it  occurs  in  many  who  do  not  develop  tuberculosis,  and  is  only  useful 
as  an  index  to  the  constitution.  The  majority  of  patients  in  the  begin- 
ning show  no  unusual  texture  or  quality  of  their  skin,  but  as  the  dis- 
ease advances,  and  wasting  occurs,  trophic  changes  in  the  skin  very 
commonly  appear,  and  in  advanced  cases  are  very  pronounced,  the  skin 
being  thin,  relaxed,  and  pale.  In  such  cases  the  skin  is  practically 
never  normal,  being  either  unduly  dry  or  moist  and  clammy. 

This  dryness,  with  a  fine,  branny  desquamation,  is  the  pifi/riads 
tahcscentinm  so  often  noted,  and  by  some  has  been  classed  as  a  diag- 
nostic sign,  but  it  is  not  in  any  way  confined  to  this  disease.  Pilyrinsis 
versicolor,  sharply  marked,  yellowish  or  even  orange-colored  patches, 
slightly  elevated  and  tending  to  gradually  coalesce  into  larger  and  larger 
masses  with  rounded  borders,  is  due  to  the  inurnaporon  furfur,  and  is 
fairly  common,  especially  in  the  lower  classes,  witli  whom  water  and 
soap  are  not  popular,  but  is  not  often  seen  in  patients  of  the  better 
classes.  It  is  chiefly  found  on  the  lower  thorax  and  upper  abdomen, 
and  on  the  back  about  the  scapul?^,  and  usually  yields  to  ablutions  and 
antiseptics. 

Shively  ("00)  reports  in  liis  dispensary  cases  a  waxy  pallor  of  the 
end  of  the  nose,  spotted  over  with  distinctly  prominent  brownish-yellow 
openings  of  the  sebaceous  glands.  The  same  is  also  seen  on  the  chin. 
He  considers  it  common  enough  to  have  diagnostic  value.  The  writer 
has  not  been  able  to  find  it,  however,  in  his  cases.  The  skin  of  advanced 
cases  will  at  times  show  purpuric  spots  shortly  before  the  end. 

The  hectic  fusli  of  tuberculosis  varies  from  a  scarcely  perceptible 
pink  spot,  sometimes  seen  quite  early  in  the  disease,  to  a  blotch  of 
brilliant  red  in  the  midst  of  the  deadly  pale  skin  of  an  advanced  con- 
sumptive. By  it  one  can  roughly  guess  the  chief  seat  of  the  trouble,  as 
it  is  very  generally  confined  to  the  cheek  of  the  involved  side,  or  if 
bilateral  is  much  more  marked  on  the  worse  side.     Owing  probably  to 


SUBJECTIVE   SYMPTOMS  193 

nervousness,  many  patients  during  an  examination  sweat  very  freely 
frojn  the  axilla^,  the  perspiration  running  from  them  in  rapidly  follow- 
ing drops,  hut  this  is  not  confined  to  tuherculosis,  being  also  seen  in 
very  nervous  people. 

As  in  all  other  exliausting  diseases,  edema  appears  near  the  end, 
and  indicates  a  failing  lieart.  Tlie  Hippocratic  chihhed  fingers,  a  bul- 
bous enlargement  of  the  ends  of  tlie  fingers,  and  at  times  of  the  toes,  is 
due  not  to  any  change  of  the  bones,  as  was  once  siipposed,  but  to  an 
increase  in  the  fibrous  tissue  of  the  part.  It  generally  develops  slowly 
in  chronic  cases,  especially  if  much  suppuration  is  present,  but  at  times 
comes  on  i-apidly,  as  in  a  case  reported  by  West,  which  developed  in 
less  than  two  weeks.  Pollock  found  it  in  twenty-nine  per  cent  of  all 
his  cases.  Kuehle  and  Cornet  ascribe  it  to  interference  with  the 
return  cii(iil;itinn,  and  Sokolowski  ('06)  to  the  wasting.  Since  it 
occurs  in  congenital,  right-sided  heart  lesions,  the  former  explanation 
seems  the  more  reasonaljle.  It  is  not  confined  to  tuberculosis,  being 
even  more  marked  in  simple  ])ronchiectasis,  and  especially,  as  noted, 
in  right-sided  heart  trouble.  Even  when  clubbing  is  not  present,  the 
finger  nails  tend  to  become  unduly  arched,  and,  like  the  teeth,  are  likely 
to  show  transverse  and  longitudinal  ridging,  the  former  marking  periods 
of  lowered  vitality.  The  cyanosis  of  the  skin  has  already  been  referred 
to.     (See  Cyanosis.) 

The  Hair. — The  hair  in  early  cases  is  just  as  apt  to  be  strong  and 
coarse  as  silky,  fine,  and  red  or  golden,  though  for  centuries  such  hair 
has  been  supposed  to  be  typical  and  to  be  associated  with  a  lessened 
resistance  to  this  disease.  In  the  later  stages  the  hair  shares  in  the 
general  denutrition,  and  is  dry,  lusterless,  and  lifeless. 

The  Psychical  Condition. — In  tuberculosis  the  psychical  condition 
varies  between  wide  limits,  and  since  there  has  been  an  undue  tendency 
to  accentuate  the  psychical  abnormalities  of  these  patients,  it  is  well  in 
the  beginning  to  note  that  a  large  number  of  patients  are  absolutely 
normal  people — people  who  can  and  do  face  with  courage  and  indomit- 
able determination  the  sad  changes  in  tlieir  lives  brought  about  by  the 
disease;  who  choke  back  the  tears  and  groans  that  would  seem  almost 
excusable,  and  put  on  a  brave  face  to  meet  misfortune.  Every  physi- 
cian can  recall  many  such  whose  courage  and  cheerfulness  compelled 
his  admiration,  and  in  wlinm  there  was  no  trace  of  tliose  mental  changes 
dwelt  on  by  Heinzelmann  ("!»4).  F.  Wolff  ('9-1),  referring  to  this  au- 
tlior's  views,  wisely  says  that  the  various  morbid  mental  states  which  he 
considers  the  results  of  tuberculosis  are  much  more  likely  its  precursors, 
and  that  in  these  peculiarities  of  character  we  can  often  find  the  cause 
of  the  disease.  Fox  ('91)  also  says:  "While  phthisis  may  occur  in 
persons  of  any  mental  constitution,  it  does  not  appear  sensildy  to  modify 
14 


194  SYMPTOMATOLOGY   OF    PULMONARY   TUBERCULOSIS 

that  peculiar  to  the  individual,  and  in  consequence  at  times  all  varia- 
tions may  be  observed." 

Wolff  divides  people  into  those  of  sanguine  and  those  of  phlegmatic 
temperament,  and  notes  that  the  former  were  far  more  numerous  among 
his  tuberculous  patients,  a  fact  which  every  man  who  handles  this 
trouble  will  have  recognized.  The  disease  is  apt  to  pick  for  its  own  an 
undue  number  of  the  high-strung,  the  unduly  sensitive,  the  talented, 
often  the  intellectually  brilliant,  as  the  history  of  literature  shows,  a 
point  which  has  been  dwelt  on  by  Osier  and  by  WolfP.  The  tempera- 
ment of  such  people  tends  also  to  make  them  poor  patients,  while  those 
of  less  emotional  and  calmer  dispositions  tend  to  do  very  well. 

In  its  incipiency,  an  excessive  and  undue  irritability  and  excitability 
are  almost  the  rule.  A  man  formerly  good-tempered  and  easy  to  live 
with,  will  become  captious  and  cross,  and  will  be  a  sore  trial  even  to 
those  who  love  him  most.  It  may  be  that  the  products  of  the  germ 
may  at  this  stage  produce  an  irritation  of  the  cortex,  but  anyone  who 
has  personally  realized  what  it  is  to  learn  that  so  dread  a  disease  has 
picked  him  for  a  victim,  who  knows  what  it  means  to  have  to  change 
cherished  ])lans  and  ambitions  and  dreams;  what  it  brings  of  anxieties 
for  the  future  for  himself  and  for  dear  ones,  will  l)e  apt  to  consider 
that  such  a  condition  is  very  natural,  and  not  necessarily  a  part  of  the 
disease;  which  seems  the  more  probable  as  this  irritability  is  not  so 
commonly  found  in  women,  and  not  at  all  in  children,  and  as,  after 
the  first  few  months,  when  the  patient  has  adapted  himself  to  the 
inevitable  and  understands  better  the  nature  of  the  trouble,  it  generally 
passes  off. 

As  the  patient  recovers  from  the  shock  caused  him  by  realization 
of  his  condition  he  usually  regains  his  equipoise,  and  is  reasonably 
cheerful  and  hopeful;  those  who  are  permanently  cast  down  being  those 
more  naturally  pessimistic  by  temperament  or  undiily  excitable  and 
nervous.  In  every  sanatorium  wiW  be  found  many  who,  to  the  doctor, 
knowing  well  their  physical  and  financial  condition,  are  a  source  of  sur- 
prise and  admiration.  Sucli  ])atients  often  serve  as  centers  of  brightness 
and  hope  to  a  whole  household,  and  change  what  might  easily  be  a  sad, 
depressed  collection  of  invalids  into  a  jolly,  bright,  laughing  crowd  of 
"  good  fellows."  In  a  large  number  of  cases,  however,  depression  is 
severe  and  difficult  to  overcome.  This  occurs  generally  in  people  of  a 
naturally  morbid  or  pessimistic  frame  of  mind,  and  it  is  worth  noting 
that  this  depression  is  more  apt  to  trouble  patients  living  in  their  own 
houses,  often  with  affectionate  relatives,  than  those  living  with  other 
patients  in  special  houses,  where  there  is  some  demand  made  upon  them 
to  go  outside  of  themselves  and  enter  into  the  interests  of  other  people. 
It  is  hardly  necessary  to  dwell  on  the  bad  effects  of  such  tendencies  to 


SUBJECTIVE   SYMPTOMS  195 

depression,  and  it  will  tax  all  the  ])h3-sician's  magnetism  and  force  to 
lift  these  ])eople  out  of  the  "  slough  of  despond  "  and  give  them  a  more 
normal  mental  attitude. 

Neurasihejiic  symptoms  are  prominent  in  a  large  number  of  cases 
of  pulmonary  tul)erculosis,  and,  as  would  be  supposed,  are  unusually 
common  among  Jewish  patients,  who  rarely  have  a  normal  nervous  sys- 
tem, and  who,  when  their  active  minds  are  taken  off  outside  affairs, 
concentrate  them  on  their  physical  condition,  with  bad  effect.  Fleeting 
thoracic  pains,  never  staying  long  at  one  spot,  and  which  give  the 
patient  a  good  deal  of  needless  anxiety,  are  amazingly  common  among 
Hebrews,  so  that  I  have  come  almost  to  expect  them  with  these  patients. 
Irritative  useless  cough,  liot  flushes,  which  are  taken  for  fever,  sleep- 
lessness, needless  worry  over  trifles,  are  annoying  and  common  in  the 
hypernervous  and  neurasthenic.  Sucli  patients  are  apt  also  to  be  vari- 
able and  excitable  and  to  lack  will  power,  and  since  persistence  and  will 
are  almost  essential  to  our  patients  if  a  j^ermanent  cure  is  to  be  accom- 
plished, the  whole  temperament  of  these  patients  will  have  to  be  re- 
formed, and  the  doctor  v\ill  have  to  strive  to  awake  and  cultivate  in 
them  energy,  hojjefulness,  and  will. 

Sleeplessness  is  very  common  in  moderate  degrees,  but  the  writer  has 
not  met  witli  it  very  often  in  severe  forms.  It  may  be  an  evidence  of 
an  emj)ty  stomach,  yielding  to  food,  or  of  unsuspected  night  fever,  but 
it  may  also  be  of  nervous  origin. 

The  intellect  is  unchanged,  and,  indeed,  is  very  often  remarkably 
clear,  though  it  is  more  quickly  exhausted,  like  the  rest  of  the  body; 
but  the  world  would  be  distinctly  poorer  if  all  the  productions  in  litera- 
ture and  art  of  consumptives  were  wiped  out,  and  one  need  only  recall 
Robert  Louis  Stevenson,  Chopin,  Rachel,  and  Heine  as  a  few  among 
many  whose  work  is  part  of  the  prized  literary  and  artistic  heritage  of 
mankind. 

It  is  in  the  last  stages  chiefly  that  we  usually  find  the  spes  phthisi- 
coriini,  the  groundless  hopefulness  of  the  consumptive,  which  has  been 
so  often  noted  by  writers  on  this  disease,  and  which  leads  almost  mori- 
bund ])atients  to  look  with  certainty  to  approaching  cures  on  every 
slight  diminution  of  temperature  or  symptoms,  and  to  nuike  plans  for 
their  future  on  their  very  deathbeds.  However,  this  is  not  by  any  means 
as  common  as  it  is  generally  held  to  be,  though  at  times  it  does  unques- 
tionably do  much  to  lighten  the  gloom  of  a  ])atient's  last  days.  The 
profession  has  often  been  blamed  for  sending  hopeless  consumptives 
away  to  resorts,  but  in  their  justification  it  should  be  remembered  that 
these  sad  and  useless  journeys  are  very  often  due  to  the  patient  and 
not  to  the  physician,  the  former  being  convinced  that  all  he  needs  to 
put  him  on  his  feet  is  such  a  change. 


196    SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

The  insanity  of  tuberculosis,  while  dwelt  on  in  text-hooks  of  psychi- 
atry, will  be  rarely  seen  outside  of  asylums,  where  at  times  as  a  pre- 
cursor, much  more  frequently  as  a  sequel,  of  insanity,  tuberculosis  is 
frequent,  accounting  for  a  large  number  of  the  deaths  in  these  insti- 
tutions. The  writer  has  had  experience  with  but  a  few  cases  of  the 
suspicious  and  melancholic  forms.  It  can  be  of  various  varieties,  but 
Regis  ('95)  quotes  Clouston  as  considering  mania  of  suspicion  the  most 
common  form.  Next  to  these  is  acute  melancholia,  with  suicidal  tend- 
encies, while  mania,  dementia,  and  general  paralysis  are  much  less  com- 
mon. Chartier  ('99)  says:  "  It  begins  by  alteration  of  the  temperament 
and  character,  and  continues  with  occasional  acute  delirious  attacks,  and 
ends  in  a  melancholic  depression,  with  ideas  of  persecution  (mania  of 
suspicion)."  (In  this  state  the  writer  has  known  patients  to  shut  them- 
selves up  in  their  houses  and  refuse  to  see  anyone  at  all  and  to  reject 
assistance  of  any  sort.)  "  In  the  last  phase  the  patient  falls  into  a 
sort  of  half  stupor,  or  has  a  terminal  attack  of  acute  mania.  This  type 
exists,  but  it  is  nevertheless  not  general." 

The  peripheral  nerves  in  tuberculosis  are  at  times  a  source  of  symp- 
toms. As  in  all  depleting  diseases,  neuralgia  is  common,  both  in  the 
extremities  and  more  especially  in  the  thorax,  where  it  ma}^  be  mistaken 
for  pleurisy,  though,  unlike  the  latter,  it  is  not  increased  by  deep 
breathing  or  pressure. 

Hyperalgesia  of  the  skin  of  the  chest  is  quite  common,  and  is  dis- 
covered frequently  during  percussion.  It  is  commonest  over  the  seat  of 
active  pulmonary  lesions  and  during  acute  congestions. 

Neuritis  has  been  reported  in  the  late  stages,  especially  in  the  oft- 
quoted  article  of  Pitres  and  Vaillard  ('86).  They  divide  it  into 
(1)  a  latent  form,  (2)  an  amyotrophic  form,  and  (3)  a  sensory  form. 
The  former  gives  no  signs  in  life  and  is  only  found  at  autopsies;  in  the 
amyotrophic  form  there  is  generally  degenerative  motor  trouble,  and  in 
the  sensory  foi-m  there  are  pains,  paresthesia?,  hyperesthesise,  and  anes- 
thesia. In  a  few  cases  the  writer  has  met  with  obstinate  sciatica,  not 
due  to  Pott's  disease. 

The  Special  Senses. — JSTo  s^anptoms  are  presented  by  the  special 
senses,  unless  we  so  consider  the  unilateral  pupillary  dilatations  which 
are  found  not  infrequently  (6.8  per  cent  in  Schaumann's  cases,  quoted 
by  Cornet).  Grober  ('05)  claims  that  widening  of  the  pupil  on  the 
affected  side  is  of  value,  and  can  be  brought  out,  when  not  present,  by 
forced  breathing,  which  dilates  the  apex  and  thus  causes  pressure  on 
the  sympathetic.  According  to  Turban  ('99),  Eogne,  in  1869,  first 
noted  this  dilatation.  The  writer  has  found  it  as  often  on  the  good 
side  as  on  the  bad,  so  that  it  cannot  be  relied  on  in  diagnosis.  In  severe 
cases,  especially  in  the  young,  he  has  noted  large  dilated  pupils  quite 


SUBJECTIVE   SYMPTOMS  197 

commonly,  and  has  come  to  attach  a  bad  prognostic  significance  to  them, 
as  showing  a  severe  degree  of  toxemia. 

The  Larynx. — It  is  unfortunate  that  an  examination  of  the  larynx 
is  so  generally  omitted  from  a  plwsical  examination  of  the  lungs.  It 
is  a  most  important  part  of  the  respiratory  tract,  and  shows  involvement 
in  a  large  number  of  cases,  Schech  ('98)  reporting  trouble  present  in 
30  per  cent  of  all  cases  of  pulmonary  tuberculosis,  Turban  in  18.3 
per  cent,  and  it  often  gives  very  early  symptoms,  so  that  we  cannot 
afford  to  overlook  it.  The  use  of  the  laryngoscope  is  not  difficult  to 
acquire,  and  every  physician  can  learn  to  recognize  not  only  those 
advanced  changes,  such  as  pear-shaped  arytenoids,  turbaned  epiglottides, 
perichondritis,  or  extensive  ulcerations  of  the  cords,  which  generally 
imply  a  fatal  outcome  of  the  case,  but  also  the  much  more  important 
slight  early  changes  which  are  still  curable,  and  which  can  be  of  assist- 
ance in  early  diagnosis   (see  Plate  I). 

In  incipient  cases  of  tuberculosis  a  weak  voice  has  long  been  recog- 
nized, even  by  the  lay  public,  as  suspicious  and  suggesting  a  weak  chest. 
While  this  is  frequentlv  the  result  of  a  slight  laryngeal  catarrh,  it  can 
also  at  times,  as  Fraenkel  ('04)  notes,  arise  from  an  improper  inner- 
vation, and  when  due  to  unilateral  cord  paralysis  is  due  to  pressure  on 
the  nerves  by  tuberculous  glands,  and  not  to  any  tuberculous  deposit  in 
the  larynx.  A  slight  lar^-ngeal  catarrh  is  present  in  a  large  number  of 
cases — 16  per  cent  of  300  cases  reported  by  Behr.  In  these  cases 
the  cords  and  arytenoids,  instead  of  being  congested  in  a  mottled  way, 
as  is  the  case  in  tuberculous  trouble,  are  evenly  congested,  and  this, 
while  possildy  favoring  a  later  development  of  tuberculosis,  is  not  itself 
of  a  tuberculous  nature  and  will  often  yield  to  proper  treatment. 

As  Chiari  ('05)  well  says:  "All  tuberculous  people  have  a  pallor 
and  poor  resisting  power  of  the  upper  respiratory  tract,  and  especially 
of  the  lar\Tix,  therefore  they  have  a  tendency  to  chronic,  and  also  acute, 
recurring  catarrhs.  Especially  are  such  cases  suspicious  in  which  one 
side  of  the  larynx,  a  cord  or  arytenoid  cartilage,  is  persistently  red  and 
thickened.  Such  patients  are  often  hoarse.  They  are  very  sensitive  to 
impure  air,  especially  tobacco  smoke.  Their  voices  tend  to  get  hoarse 
and  tire  quickly  on  speaking.  Many  tuberculous  people  never  have  any 
other  laryngeal  s_\Tnptoms  than  these." 

The  first  symptoms  of  a  tuberculous  laryngitis  are  a  tickling  or 
pricking  sensation  in  the  throat,  as  if  one  had  swallowed  a  bristle,  with 
some  dryness  and  cough.  Hoarseness,  except  as  an  impurity  of  the 
voice,  is  not  at  first  present,  and  is,  indeed,  often  absent,  even  when 
extensive  lesions  are  found  in  tlie  larynx. 

Dysphagia  is  practically  never  present  in  early  cases,  although  the 
patient  often  complains  of  "  feeling  his  larynx "  on  swallowing,  and 


198  SYMPTOMATOLOGY   OF   PULMONARY  TUBERCULOSIS 

most  patients  complain  of  some  discomfort  or  uneasiness  in  their  throats, 
wliich  they  can  generally  localize  correctly  to  the  affected  side,  if  the 
process  is  unilateral. 

The  earliest  general  change  is  either  an  anemia  or  a  hyperemia  of  the 
larynx.  Formerly  anemia  of  the  larynx  was  considered  a  very  typical 
early  sign,  hut  it  is  not  found  as  frequently  as  hyperemia,  and  Lennox- 
Brown  ('J)9)  quotes  Cohen,  wlio  says  that  "  liyperemia  is  the  earliest  sign 
in  the  acute,  and  anemia  in  the  chronic  form."  The  writer's  experience 
is  that  anemia  is  common  if  tlie  patient  chances  to  he  otherwise  anemic 
or  run  down  when  tiie  })rocess  develops,  but  unless  other  changes  in  the 
mucous  mendjrane  are  present  it  is  not  a  sign  to  be  relied  on. 

The  really  valuable  changes  in  this  stage  in  the  laryngoscopic  pic- 
ture are  changes  in  tlie  posterior  commissure,  the  processus  vocalis  or 
body  of  the  true  cord,  or  in  tbe  false  cords  or  arytenoids,  the  epiglottis 
and  anterior  commissure  at  tliis  time  not  usually  being  affected.  Of  all 
these  locations,  tbe  posterior  commissure  is  very  much  the  most  com- 
mon, Jurasz  ('0-t)  finding  it  the  primary  seat  in  195  of  378  cases. 
The  mucous  membrane  of  the  posterior  commissure  is  either  wrinkled 
and  elevated  into  numerous  grayisli  folds,  which  seen  from  above  look 
like  fine  scallops  running  from  side  to  side,  or  showing  a  general  or 
more  usually  localized  thickening,  or  tablelike  elevation  (see  Plate  I, 
Fig.  1). 

Of  the  changes  above  noted  the  writer  lias  found  tbe  grayish  wrink- 
ling (Fig.  (!)  to  be  the  commonest  early  finding,  but  since  it  can  be  simu- 
lated by  a  chronic  catarrb,  it  has  not  tbe  diagnostic  value  of  the  tablelike 
elevation.  This  elevation  generally  occupies  the  center  of  the  commis- 
sure, and  iisually  has  a  vertical  furrow  or  depression  down  its  center, 
dividing  it  into  two  ordinarily  symmetrical  lialves.  At  first  it  is  but 
slightly  elevated  above  the  surface,  but  tends  to  get  larger  and  larger, 
until  it  can  stand  out  in  a  tumorlike  mass.  Schnitzler  ('95)  considers 
it  "  one  of  the  sure  signs  of  tbe  beginning  of  tuberculosis,  and  when  it 
has  reached  a  certain  degree,  an  almost  certain  sign  of  the  l)eginning 
of  phthisis,  even  without  other  appearances,  and  even  while  the  patient 
is  in  the  best  of  health." 

The  color  is  generally  grayish-pink,  but  Schnitzler  insists  that  this 
grayish  color  is  not  in  itself,  and  aside  from  the  elevation,  of  any  sig- 
nificance, and  that  it  can  occur  in  chronic  laryngitis.  Keller,  quoted 
by  Schech  ('98),  found  such  tablelike  elevations  in  thirty-six  out  of 
forty-eight  cases.  They  can  at  times  exist  for  years  before  the  develop- 
ment of  active  pulmonary  troulile.  While  the  thickening  is  usually 
localized  to  the  surface  of  the  posterior  commissure,  at  times  infiltra- 
tion will  include  the  whole  breadth  of  the  arytenoids,  thickening  them 
greatly  from  before  backward. 


PLATE  I 


— (HS" 


1 


. — Tablelike   Thickening    and 

VATION     OF     THE     MUCOVS     MeM- 

NE  OF  THE  Posterior  Commis- 
E.  The  Mrcous  Membrane  is 
ally    Rather     Reddened,    but 

BE  EDEMATOrS  AND  HeNCE  YeL- 

^ish.      (After  Tiirck.) 
> — Small   Erosions   or  Ulcers 
^reeBorder  of  the  Cords  Giving 
;  Characteristic  "Xibbled-out" 
'EARANCE.      (After  Schnitzler.) 


3. — Thickening  of  the  Rigi 
False  Cord  which  Overlaps  a> 
Hides  Most  of  the  True  Cor 
There  is  also  Moderate  Thicke: 
ing  of  the  Center  of  the  Aryt 
noid  Region.     (After  Tiirck.) 

4. — Thickening  and  Injectk 
OF  Insertion  of  Cords  and  S.m.\ 
Ulcer  at  the  Base.  (After  Schiiit 
ler.) 


5. — Superficial  Erosion  of  the 
fER  Surface  of  the  Vocal  Cords, 
jy  Typical  of  Tuberculosis.  In- 
tion  of  Cords.  (After  Krieg.) 
6. — Grayish  Wrinkling  of  the 
jTERiOR  Commissure,  not  Di.\g- 
iTic,  but  very  Suspicious  if  Com- 
ed   with  Other    Sy.mptoms.     Of 

5S  V.\LUE   in   those   WHO  USE   THE 

ICE  IN  Public  Spe.^king.     (After 
initzler.) 


7. — Ulceration  of  the  Fi 
Border  of  the  Right  Cord,  P 
nuciNG  THE  Appearance  of  a  Re 
plication  of  the  Cord.  (A: 
Krieg.) 

S. — W.vrtlike  Growth,  Ris 
FR<1M  the  Posterior  Commissi 
Xear  the  Insertion  of  the  C< 
(a  Favorite  Location).  (A 
Krieg.) 


SUBJECTIVE   SYMPTOMS  199 

These  tablelike  elevations  tend  to  break  down  into  idcers,  but  as 
such  ulcers  are  seen  in  profile  from  above,  and  as  their  bases  tend  to 
fill  with  exuberant  pointed  granulations,  which  hide  the  ulcer  itself 
entirely,  their  nature  may  be  mistaken.  Later  on  these  granulations 
may,  and  often  do,  enlarge  to  such  an  extent  as  to  greatly  affect  the 
voice  and  embarrass  respiration.  In  the  place  of  such  infiltrations  we 
have  at  times  tumorlike  masses,  althougli  these  are  hardly  an  early 
occurrence.  These  solid  excrescences  or  granulomata  (Fig.  8)  do  not 
break  down  as  do  the  infiltrations,  but  can  persist  for  a  long  time  un- 
changed, and  are  usually  associated  with  a  benign  course,  and  are  so 
firm  and  fibrous  in  texture  as  to  render  their  removal  difficult.  At  times 
we  find,  instead,  pointed  or  even  forked  papillomata. 

iS^ext  to  the  posterior  commissure  as  the  site  of  early  changes  is  one 
cord,  and  more  especially  the  posterior  insertion  of  a  single  cord  and 
its  processus  vocalis  (Fig.  4).  At  this  latter  point  we  will  often  find  very- 
early  some  thickening  and  reddening,  which  soon  develops  into  a  small 
ulcer  with  a  wdiite  slough,  but  its  tuberculous  nature  is  not  as  easily 
determinable  as  are  the  changes  in  the  commissure. 

Lake  ("01)  considers  paralysis  of  the  cord  an  early  sign  and  due 
to  a  tuberculous  myositis  or  to  a  toxic  effect.  The  writer  has  found 
paralysis  of  the  arytenoideus,  but  not  in  incipient  cases.  The  cord  itself 
shows  either  patches  of  congestion,  going  on  to  ulcer  formation,  or  a 
solid,  red,  brawny  infiltration  of  its  whole  length,  by  wdiich  it  loses  its 
luster  and  becomes  spindle-shaped. 

This  is  followed  by  erosions  of  the  free  edge  or  upper  surface  and 
the  formation  of  ulcers.  The  ulceration  of  the  edge  is  frequently  in 
spots,  so  that  the  cord  looks  as  if  small  pieces  had  been  nildiled  out  of 
its  edge  (Fig.  2),  or  it  may  extend  the  whole  length,  in  which  case  the 
parallel  edges  of  the  ulcer  give  the  cord  the  appearance  of  being  redu- 
plicated (Fig.  7).  The  characteristic  feature  of  tuberculous  ulcers  is 
their  multiple  character  and  their  tendency  to  coalesce  and  extend  later- 
ally, rather  than  deeply  (Fig.  5).  Such  ulcers  on  the  cord  are  much 
conmioner  in  the  posterior  third  or  one  half,  and  frequently  this  [)ortion 
is  entirely  eaten  away  while  the  anterior  portion  is  well  preserved. 

In  the  false  cords  there  is  most  often  a  very  marked  thickening  and 
infiltration  which  broadens  the  cord  considerably  so  that  it  overlaps,  and 
often  entirely  hides,  the  true  cord  below  (Fig.  3),  like  a  folded  blanket. 
The  congestion  is  apt  to  be  patchy,  with  areas  of  yellowish  pallor 
between,  and  the  surface  of  the  cord  granular,  and  in  early  cases  ulcers 
are  not  common.  The  arytenoids  often  show  for  a  long  time,  before 
definite  lesions  are  found,  localized  patches  of  redness,  so  that  they  Iodic 
mottled  and  angry  (P'ig.  4),  with  sometimes  a  wiiite  spot  of  anemia 
where  the  cartilage  of  Santorini  projects. 


200  SYMPTOMATOLOGY   OF   PULMONARY  TUBERCULOSIS 

In  early  cases  they  are  not  usually  much  enlarged,  but  at  times  will 
be  found  conaiderably  swollen.  The  pear-shaped  swelling  running  into 
the  aryepiglottidean  folds  is  of  later  appearance.  The  anterior  com- 
missure, as  noted,  is  usually  free  at  this  time,  but  now  and  again  there 
is  seen  protruding  through  the  anterior  ends  of  the  cords  a  small 
polypoid  mass  of  red  granulation.  The  epiglottis  at  most  shows  small 
localized  areas  of  thickening  of  its  sharp  upper  edge,  ulcers  of  its  edge, 
the  turban-shaped  swelling  and  the  edema  of  the  epiglottis  and  ary- 
epiglottidean folds  not  being  early  changes.  In  the  same  way,  the  ring- 
like  ulceration  involving  the  posterior  commissure  and  both  cords  is  also 
a  much  later  condition  and  usually  implies  severe  and  hopeless  trouble. 

Severe  dysphagia  and  aphonia  are  also  late  symptoms,  but  if  tlie 
arytenoids  ulcerate  early  the  former  may  be  present.  Aphonia  usually 
accompanies  ulceration  of  the  cords,  and  is  not  associated  with  dys- 
phagia, while  the  dysphagia,  which  is  often  extreme  and  harassing,  and 
yields  to  no  anodynes,  is  commonest  when  there  is  epiglottic  ulceration 
or,  to  a  less  degree,  trouble  with  the  arytenoids. 

Perichondritis  of  the  larynx  is  never  seen  in  early  cases,  but  gen- 
erally results  from  infection  of  the  cartilage  from  deep  ulcers,  the  infec- 
tion finally  dissecting  out  the  cartilage,  which  is  thrown  off  as  a  seques- 
trum.    It  is  accompanied  b}^  agonizing,  throbbing  pain. 

In  conclusion,  it  must  be  noted  that  usually  the  earliest  tuberculous 
laryngeal  manifestations  are  coincident,  not  with  very  incipient  pul- 
monary lesions,  but  with  moderately  .advanced  ones,  and  that  while 
primary  laryngeal  tuberculosis  can  exist,  laryngeal  involvement  is  not 
usually  determinable  in  pulmonary  tuberculosis  until  a  considerable  time 
after  that  in  the  lung. 

Cough  is  one  of  the  earliest  and  most  constant  symptoms  of  pul- 
monary tuberculosis  (Eoepke  reported  it  in  93.8  per  cent  of  144  first- 
stage  cases),  and  is  so  rarely  absent  that  Euehle  ('87)  says:  "There 
is  no  consumption  without  cough,"  and  while  this  is  subject  to  certain 
exceptions,  it  is,  on  the  whole,  a  fair  statement.  A  large  percentage 
of  early  cases  give  a  history  of  cough,  or  at  times  of  clearing  of  the 
throat,  as  the  first  change  noted;  no  other  symptom  is  so  often  the 
first  to  appear.  Aufrecht  ('05),  it  is  true,  denies  this,  saying  that  the 
cough  of  consumption  is  onl}'  a  sequel  of  the  laryngeal  catarrh,  and 
that  such  consumptives  as  have  no  lar}Tigeal  catarrh  have  no  cough, 
but  while  patients  in  the  incipient  stage  often  have  a  cough  of  laryngeal 
origin  (see  Lar}Tix),  Aufrecht  is  alone  in  regarding  it  as  the  only  cause 
of  the  early  cough.  He  seems  to  be  contradicted  by  the  fact  experi- 
mentally determined  by  Nothnagel  and  others  ('94)  that  irritation 
of  the  diseased  pleura  produces  cough  in  the  alisence  of  any  laryngeal 
catarrh.     Moreover,  knowledge  of  the  cough-producing  effects  of  pleu- 


SUBJECTIVE   SYMPTOMS  201 

ritic  troiiljle  would  lead  one  to  anticipate  a  pleurogenic  cough  in  a 
disease  in  which  an  apical  pleurisy  is  such  an  early  occurrence.  Cer- 
tainl}^  some  cough  is  present  in  a  large  majority  of  all  cases,  and  per- 
sistent absence  of  cough,  as  Lindsay  ('04)  sa3's,  points  to  the  absence 
of  tuberculosis. 

The  incipient  cough  is  often  preceded  for  some  time  by  a  weak  voice 
which  loses  its  timbre,  or  by  a  so-called  nervous  clearing  of  the  throat, 
which  occurs  especially  with  every  change  of  the  weather.  In  such  cases 
there  is  at  first  only  a  slight  "  ahem,"  which  is  not  very  noticeable  and 
which  is  often  completely  overlooked  by  the  patient,  though  noticed  by  his 
family.  Tbis  occurs  chiefly  in  the  morning,  and  while  a  morning  cough 
or  clearing  of  the  throat  cannot  be  regarded  as  pathognomonic,  it  is 
always  a  very  suspicious  symptom.  Such  a  cough  is  due  either  to  a 
sligbt  laryngeal  catarrh  or,  as  Grancher  ('97)  notes,  to  an  irritation 
of  the  terminal  filaments  of  the  pneumogastric  nerve  in  the  lung,  pleura, 
or  bronchial  glands.  It  should  be  distinguished  from  the  hysterical 
cough,  which  never  occurs  in  sleep  and  remains  the  same  indefinitely. 
At  first  it  is  not  productive  of  any  sputum,  but  this  is  seldom  long 
absent  if  carefully  looked  for.  It  is  almost  always  a  morning  cough  at 
first,  Grancher  being  alone  in  considering  it  an  evening  one. 

Instead  of  developing  insidiously,  it  often  begins  suddenly,  in  the 
form  of  a  bronchitis,  the  patient  reporting  that  he  "  caught  cold,"  and 
so  many  patients  are  treated  for  a  long  time  for  bronchitis,  that  it 
would  be  wise  if  every  cough  lasting  more  than  a  month  were  consid- 
ered strongly  suspicious  of  tuberculosis.  The  tuberculous  cough  at  first 
disappears  with  warm  weather,  to  reappear  in  the  fall,  the  patient  being 
thus  led  to  harbor  a  false  sense  of  security.  However,  when  once  well 
established,  it  does  not  stop  in  summer,  though  it  is  generally  less  in 
warm,  dry  weather. 

Nothnagel's  researches  have  shown  that  the  respiratory  mucous 
membrane  is  more  sensitive,  and  that  its  irritation  more  quickly  pro- 
duces a  cough  in  the  area  of  supply  of  the  superior  laryngeal  nerve, 
especially  the  interarytenoid  space,  rima  glottidis,  and  epiglottis,  and 
that  this  sensitiveness  lessens  lower  do^Ti,  temporarily  increasing  again 
at  the  bifurcation.  In  the  bronchi  it  is  slight,  and  tbc  parenchyma  is 
insensitive,  while  the  pleura  is  only  sensitive  when  inflamed.  Krishaber 
found  that  superficial  lesions  cause  more  cough  than  deep  ones,  which 
corres])onds  with  clinical  experience,  pleural  lesions  causing  more  cough 
than  any  otbers  except  tbe  laryngeal. 

At  the  same  time  it  must  be  remembered  that  there  are  few  more 

obstinate  or  more  painful  coughs  than  tbose  of  abscess  of  the  lung,  or 

those  caused  by  a  focus  of  acute  softening,   and  unless  such  a  cough 

is  due  to  a  neigliboring  jileurisy  or  to  irritation  of  tbe  bronchi,  it  would 

15 


202    SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

seem  to  speak  for  an  irritability  of  the  parenchyma  when  inflamed. 
The  early  cough  is  rarely  violent,  unless  laryngeal  or  due  to  enlarged 
bronchial  glands. 

Laryngeal  cough  is  easily  recognized  by  its  paroxysmal  nature,  dry- 
ness, great  intensity,  and  peculiar  timbre.  The  cough  due  to  enlarged 
bronchial  glands  is  croupy  and  violently  paroxysmal,  and  such  a  cough 
in  a  patient  should  suggest  tracheo-bronchial  adenopathy.  The  early 
cough  does  not  cause  pain  in  the  chest,  as  the  late  cough  often  does, 
but  the  writer  has  noted  that  it  can  give  rise  to  qiiite  a  severe  neuralgic 
pain  in  the  point  of  the  shoulder  on  the  affected  side,  a  fact  not  noted 
anywhere  except  by  Ruehle. 

While  cough,  as  is  now  so  generally  taught,  can  in  most  cases  be 
suppressed  by  will  power,  there  is  sometimes  in  early  tuberculosis  such 
an  intolerable  itching,  tickling  sensation  in  the  larynx  that  even  those 
of  strong  will  find  the  suppression  of  a  cough  impossible.  This  tickling 
is  not  always  in  the  larynx,  but  at  times  somewhere  along  the  course 
of  the  bronchial  tree,  and  is  very  commonly  felt  under  the  lower 
part  of  the  sternum,  so  that  the  patient  supposes  this  to  be  the  seat  of 
the  trouble,  but  the  tickling  bears  no  relation  to  the  site  of  the  pul- 
monary lesion.  Morton,  quoted  by  Osier,  long  ago  noted  that  the 
cough  could  produce  vomiting,  but  tbe  conception  of  an  early  case  in 
his  day  was  what  to-day  would  be  considered  an  advanced  one,  and 
although  so  good  an  authority  as  Grancher  ('97)  considers  that  the 
early  cough  of  phthisis,  while  not  producing  expectoration,  produces 
vomiting,  the  writer  has  not,  in  his  early  cases,  found  this  to  be  the 
case. 

The  effect  on  the  cough  of  the  personality  of  the  patient  is  very 
marked.  Neurotic,  excitable  patients,  especially  Hebrews,  react  most 
violently  to  cough  stimuli,  as  they  do  to  all  other  stimuli,  and  unless 
carefully  trained  will  do  a  great  deal  of  harmful  and  needless  cough- 
ing, whereas  the  quieter  and  more  phlegmatic  person  will,  with  the  same 
degree  of  trouble,  do  much  less  coughing. 

As  already  noted,  when  the  cough  has  once  begun  it  practically  never 
ceases,  except  for  short  summer  remissions  or  intermissions,  until  the 
end  or  until  arrest  of  the  trouble,  and  in  the  writer's  experience  this 
has  generally  been  the  last  symptom  to  disappear.  This  obstinacy  and 
persistence  is  one  of  the  most  typical  features  and  every  layman  knows- 
the  evil  omen  of  a  persistent  cough. 

There  is  no  typical  cough  in  tuberculosis,  and  in  all  stages  there 
may  be  a  loose  or  dry,  a  hard  or  an  easy,  a  high-pitched  or  a  deep  cough, 
though  in  general  it  is  fair  to  say  that  in  the  beginning  it  is  slight  and 
dry,  that  it  gradually  loosens  and  becomes  more  pronounced,  and  is 
exaggerated  by  each  exacerbation  or  extension  of  trouble,  and  toward 


SUBJECTIVE   SYMPTOMS  203 

the  end  is  usually  loose,  deep,  and  hollow.  On  the  other  hand  it  usu- 
ally lessens  as  the  process  improves,  and  though  Cornet  ('07)  denies 
that  cough  hears  any  relation  to  the  disease,  the  writer  helieves  he  is 
justified  in  saying  that  steadily  lessening  cough  almost  always  means 
improvement,  and  persistentl}^  increasing  cough  generally  means  the 
reverse.  As  the  process  advances  it  shows  distinct  morning  and  even- 
ing exacerbations.  The  patient  at  this  time  is  not  much  disturbed  by 
the  cough  at  night,  though  he  may  waken  once  or  twice  to  expectorate, 
but  on  awakening,  or  after  rising,  and  sometimes  not  until  after  eating, 
he  coughs  a  number  of  times,  generally  easily  unless  the  sputum  is  very 
tenacious,  and  after  having  spat  a  few  times  and  "  cleared  out  his 
chest,''  he  does  not  at  first  have  much  more  cough  during  the  day,  except 
after  eating  or  laughing  (a  prolific  cause  of  cough)  or  after  much 
talking,  exertion,  or  excitement.  At  bedtime,  or  as  soon  as  he  lies 
down  again,  he  has  another  attack  of  coughing,  though  at  this  time  the 
expectoration  is  much  less  than  in  the  morning,  and  consequently  the 
cough  is  much  more  violent. 

The  cough  at  bedtime  has  been  explained  variously.  De  Eenzi  ('9-t) 
ascribes  it  to  hyperemia  of  the  apex,  and  thus  explains  the  patient's 
tendency  to  lie  on  his  sound  side  to  prevent  cough,  also  noting  that 
lying  down  increases  dyspnea,  and  that  the  respiratory  center  is  always 
more  irrital>le  in  dyspnea.  Xagelsbuch  ('04)  believes  it  is  caused  by 
hyperemia  of  the  larynx,  and  by  the  fact  that  in  the  recumbent  position 
air  strikes  different  portions  of  the  laryngeal  mucous  membrane.  As, 
however,  cough  on  lying  down  is  not  noted  in  incipient  cases,  but  onl}^ 
when  sputum  is  present,  it  seems  to  be  sufficiently  explained  by  the 
movement  of  sputum  to  new  areas  or  by  change  of  position,  as  is  also 
the  morning  cough,  which  is  also  encouraged  by  the  returning  sensibility 
of  the  mucous  membrane  which  is  lowered  during  sleep. 

As  the  disease  progresses  and  cavities  form,  the  cough  becomes  more 
or  less  constant,  the  patient  coughing  at  more  or  less  frequent  intervals 
during  the  day  and  expectorating  at  the  same  time.  If  large  cavities 
are  present,  they  impart  to  the  cough  the  characteristic  "  hollow  ''  qual- 
ity supposed  to  be  characteristic  of  consumption.  The  constant  cough 
of  the  later  stages  can  severely  affect  the  health  by  disturbing  sleep, 
using  up  strength,  and  by  affecting  the  nutrition  by  causing  vomiting 
after  meals,  while  it  also  increases  the  danger  of  hemorrhage  and  hastens 
the  end  through  exhaustion. 

In  this  stage,  and  even  earlier,  the  chief  site  of  the  trouble  is 
severely  racked  by  cough,  which  may  make  the  lung  ache  and  cause  at 
times  sharp  pain,  especially  if  there  are  pleural  adhesions,  and  when, 
as  is  so  commonly  the  case,  such  adhesions  exist  also  at  the  base  of  the 
other  side,  the  patient  will   U'd  tlicm  with  ever}'  cough.     The  abdominal 


204    SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

muscles  at  times  become  sore  from  the  excessive  work  put  on  them  by 
the  cough,  and  advanced  cases  suffer  considerably  from  this. 

A  very  severe,  hai'd,  dry  cough  comes  with  beginning  softening, 
or  during  abscess  formation  in  the  lungs,  and  persists  until  softening 
is  completed  and  the  detritus  or  pus  has  been  evacuated  by  expectora- 
tion. When  large  cavities  exist  the  cough  is  usually  very  loose  and 
free  and  may  be  intermittent,  coming  on  in  paroxysms  until  the  cavity 
is  emptied,  the  sputum  coming  up  in  large  amounts  and  then  ceasing 
until  the  cavity  is  full  again.  Patients  with  cavities  are  usually  unable 
to  sleep  comfortably  on  the  sound  side,  owing  to  the  severe  cough  pro- 
duced by  the  contents  of  the  cavity  emptying  toward  the  dependent  side, 
but  this  is  not  the  universal  rule;  the  reverse  sometimes  is  the  case. 

In  very  sensitive  people  or  in  the  old,  or  in  those  who  have  never 
been  accustomed  to  proper  ventilation  in  their  bedrooms,  cold  air  pro- 
duces considerable  cough,  especially  if  it  is  damp.  In  the  young  or 
middle-aged  hygienic  education  and  outdoor  life  will  overcome  this  quite 
promptly,  though  at  first  every  breath  of  good  fresh  air  will  produce 
a  cough,  largely  by  autosuggestion,  but  in  the  old  it  is  often  unconquer- 
able, and  one  Cannot  expect  them  to  carry  out  an  outdoor  cure  con- 
sistently. 

An  annoying  and  often  obstinate  s^'mptom  is  a  crackling  and  rat- 
tling in  the  chest,  heard  with  every  breath,  caused  by  tenacious  mucous 
in  the  air-tubes,  and  which  can  be  heard  at  some  distance  from  the 
patient.  It  often  is  very  worrying  and  may  be  the  cause  of  bitter 
complaint,  and  while  often  yielding  to  the  use  of  alkalin  waters,  ipecac, 
or  ammonium  chlorid,  it  at  times  resists  every  effort. 

Expectoration  is  present  in  almost  all  cases  of  pidmonary  tuber- 
culosis at  some  time  in  their  course,  and  when  reported  absent  one  can 
by  no  means  be  sure  that  it  is  really  so,  many  patients  unconsciously 
swallowing  all  they  raise.  In  4,739  cases  collected  from  statistics  of 
German  sanatoria  by  Montgomery  ('06),  83.1  per  cent  had  expectora- 
tion, and  Koupke.  quoted  by  the  same  author,  found  it  present  in  77.8 
per  cent  of  144  first-stage  cases.  The  swallowing  of  sputum  is  uni- 
versal in  childhood,  up  to  at  least  the  fifth  year,  and  some  adults,  more 
especially  women,  never  get  over  the  habit,  or  else  persist  in  it  know- 
ingly from  motives  of  false  delicacy. 

A  total  absence  of  expectoration  throughout  the  whole  course  of  the 
disease.  Mobile  reported,  must  certainly  be  extremely  rare,  and  it  would 
be  most  difficult  to  prove  that  it  is  not  apparent  rather  than  real. 
Formerly  a  typical  tuberculous  sputum  was  described,  but  it  is  now 
recognized  that  such  does  not  exist,  though  certain  characteristics  of 
the  sputum  point  to  certain  physical  conditions  in  the  chest.  In  the 
very  early  stages,  when  the  cough  first  appears,  sputum  is  often  absent; 


SUBJECTIVE   SYMPTOMS  205 

thus  while  93.8  per  cent  of  Roupke's  first-stage  patients  coughed,  only 
77.8  per  cent  expectorated.  Indeed,  even  considerably  later  we  are 
often  surprised  to  find  that  many  unobserving  patients  do  not  know 
that  they  expectorate,  and  when  it  is  demonstrated  to  them,  are  apt 
to  ascribe  it  to  a  nasal  catarrh,  a  statement  which  is  always  open  to 
doubt  until  proved. 

In  most  cases,  however,  even  if  at  first  absent,  it  soon  appears, 
Fowler  and  Godlee  ('98)  believing  that  "it  is  rarely  absent  when  symp- 
toms have  been  present  for  as  long  a  period  as  two  months."  At  first 
there  is  only  a  little  mucoid,  glairy  sputum,  with  at  times  dark  points 
in  it,  and  so  full  of  air  that  it  floats  on  the  water.  Every  now  and 
then  some  transparent,  jellylike  masses,  usually  compared  to  grains  of 
boiled  sago,  or  by  Aufrecht  ('05)  to  frogs'  eggs,  are  brought  up.  These 
masses  are  composed  chiefly  of  alveolar  epithelium,  either  unchanged 
or  in  a  stage  of  fatty  degeneration,  the  result  of  an  alveolar  catarrh. 
The  sputum  slowly  increases  in  amount,  and  becomes  thicker  and  more 
dense  and  less  transparent,  owing  to  increased  cellular  content,  and 
shows  scattered  through  it  yellowish-white  flocculi,  and  while  still 
containing  enough  air  to  float,  sends  dowTi  into  the  water  long  processes 
like  streamers.  The  increase  of  formed  elements  changes  its  color  to 
a  whitish-yellow  or  a  slightly  greenish  tinge,  or  at  times  to  a  faint  pink 
shade.  As  tissue  necrosis  begins,  the  mucoid  portion  lessens  and  the 
purulent  portion  increases  until  it  is  plainly  mucopurulent  and  greenish- 
yellow  in  color,  tending  to  sink  in  water  and  showing  the  nummular 
masses  which  were  once  considered  so  diagnostic  of  tuberculosis.  These 
are  irregularly  scalloped,  rounded,  grayish,  or  greeni.sh-gray  balls,  which 
hang  from  floating  islands  of  mucus  and  saliva  by  long  strings,  if  not 
too  purulent,  or  if  .so,  sink  to  the  bottom  to  form  disk-shaped,  coinlike 
masses,  which,  however,  do  not  coalesce.  While  nummular  sputum  is 
not  pathognomonic,  as  it  can  occur  in  bronchiectasis,  it  is  fair  evidence 
of  a  cavit}^  in  the  lungs. 

In  the  late  stages  the  sputum  is  an  evenly  purulent  liquid  mass 
containing  no  air,  and  hence  sinking  to  the  bottom  of  the  water  at 
once,  where  it  makes  a  nasty  gray-green  deposit  in  which  we  can  find 
fragments  of  cheesy  matter.  In  rapidly  breaking  down  lungs  the  spu- 
tum contains  irregular  cheesy  fragments,  Avhich  Bayle  likened  to  grains 
of  boiled  rice,  and  which  he  considered  characteristic  of  tuberculosis, 
while  the  dirty,  dark-gray  sputum  seen  in  this  stage  Aufrecht  considers 
always  the  product  of  the  cavity  wall. 

At  first  odorless,  though  of  salty  taste,  it  is  in  the  late  stages  of  a 
marked  sweetish,  nauseating  odor,  and  sweetish  sickly  taste.  An  offen- 
sive odor  is  not  present  in  uncomplicated  cases  of  tuberculosis,  but  it  is 
only  found  when  abscess,  gangrene,  or  bronchiectasis  exist. 


206    SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

The  amount  of  sputum  can  vary  witliin  wide  limits,  but  in  the 
average  case,  until  cavity  formation,  it  is  quite  moderate  and  by  no 
means  so  profuse  as  in  chronic  bronchitis.  While  it  may  amount  to 
a  pint  or  more  in  twenty-four  hours,  this  is  rare,  one  or  two  ounces 
being  the  average,  and  three  or  four  ounces  being  rather  unusual.  A 
convenient  measure  is  the  commonly  used  folded  paper  sputum  cup  in 
its  tin  frame,  and  patients  in  the  early  stages  rarely  more  than  cover 
the  bottom  of  one  of  these;  patients  in  the  second  stage  are  apt  to 
expectorate  one  third  or  one  half  a  cup,  unless  tissue  destruction  is 
very  active,  while  old  cases  will  fill  one,  two,  or  even  three  cups  in 
twenty-four  hours.  An  estimate  of  the  amount  of  sputum  in  twenty- 
four  hours  should  always  be  made,  and  sudden  or  gradual  increases  or 
decreases  should  be  noted.  A  sudden  decrease  usually  presages  a  con- 
gestion, a  marked  increase  a  l)ioncliitis,  a  gradual  increase  a  breaking 
down  of  hitherto  only  infiltrated  areas,  while  a  gradual  decrease  gen- 
erally speaks  for  lessening  trouble,  decreased  ulceration,  or  the  drying 
up  of  a  cavity,  and  is  of  unquestionable  prognostic  value  if  it  persists. 
As  the  patient  improves,  the  sputum  tends  to  become  less  purulent  and 
more  white,  foamy,  and  mucoid,  and  is  apt  to  cease  entirely  much 
sooner  than  the  cough  stops. 

In  the  case  of  patients  with  purulent  sputum  who  take  up  an  out- 
door life  in  a  climatic  resort,  there  is  generally  noted  at  first  an  increase 
in  quantity  but  an  improvement  in  quality,  the  sputum  becoming  whiter, 
more  mucoid  and  foamy,  and  more  abundant,  and  only  after  this  does 
it  decrease  in  quantity  as  well.  In  examining  the  chests  of  patients 
who  have  abundant  sputum,  we  are  often  surprised  to  find  few  or  no 
signs  of  moisture,  while  often  patients  with  many  rfdes  have  little  or 
no  sputum,  but  generally  an  increase  of  sputum  is  accompanied  by  an 
increase  of  signs  of  moisture  in  the  chest. 

Ulcerative  cases  naturally  produce  much  sputum  of  a  purulent  char- 
acter, as  do  those  with  bronchiectasis,  while  acute  miliary  cases  have 
none,  save  at  times  at  the  very  end ;  but  acute  tuberculous  pneumonias, 
while  having  little  at  first,  and  that  mucoid,  when  they  begin  to  soften 
and  when  the  necrotic  area  is  being  thrown  off,  have  an  abundant  spu- 
tum, which,  if  any  gangrene  be  present,  may  be  very  offensive.  In  these 
cases  the  appearance  of  abimdant  sputum  is  usually  a  good  sign,  as  only 
by  a  throwing  off  of  the  dead  tissue  can  the  patient  possibly  advance 
to  a  cure. 

Fibroid  cases  are  characterized  by  a  scanty  sputum  throughout,  and 
that  mostly  mucoid,  or  at  most  mucopurulent.  In  improving  cases  the 
bacilli  disappear  from  the  sputum  in  al)out  fifty  per  cent,  but  not 
infrequently  they  will  be  found  in  every  specimen  until  no  more 
sputum   is  raised.      JSTaturally  those  cases  in  which   the   sputum   loses 


SUBJECTIVE   SYMPTOMS  207 

its  bacilli  before  it  disappears  may  be  regarded  more  favorably  than 
the  latter. 

As  to  the  time  of  day  when  expectoration  is  commonest,  this,  in 
early  cases,  is  chiefly  in  the  morning  on  rising,  and  during  the  day 
little  or  nothing  will  be  brought  up;  but  when  the  case  is  once  well 
developed  some  sputum  is  brought  up  off  and  on  all  day,  especially 
after  eating,  while  in  old  cases  most  of  the  sputum  is  raised  during  the 
night,  a  whole  cup  often  being  filled  in  that  time.  In  cases  near  the 
end  no  sputum  may  be  raised,  it  being  retained  in  the  lung  owing  to 
extreme  weakness,  but  if  a  patient  is  in  a  moderately  advanced  condi- 
tion and  is  raising  no  sputum  one  should  carefully  investigate  as  to 
whether  the  sputum  is  not  being  swallowed. 

When  for  any  reason  sputum  is  retained  and  not  expectorated,  it 
is  usually  soon  followed  by  rise  of  temperature,  which  falls  again  when 
evacuation  takes  place. 

Inspection  of  the  sputum  is  of  little  value  except  to  discover  the 
nummular  masses,  sago  bodies,  and  necrotic  particles.  At  times  one 
will  find  calcareous  masses,  expectorated  often  with  severe  pain.  These 
masses  originate  in  calcified  bronchial  glands  or  calcified,  foci  in  the 
apex,  and  since  calcification  is  one  of  nature's  conservative  processes, 
they  are  generally  considered  to  be  of  good  omen.  Tonsillar  plugs  may 
be  found,  and  can  be  recognized  by  their  fetid  odor  and  by  leaving  a 
greasy  mark  when  warmed  on  paper.  Small  specks  of  blood  in  the 
sputum  or  a  pink  tinging  generally  foreshadow  a  hemorrhage,  but  both 
may  continue  for  weeks  without  any  such  results.  Fibrin  and  blood- 
casts  are  seen  occasionally,  chiefly  after  hemorrhages. 

Microscopic  Examination. — While  many  morphologic  elements  can 
be  found  in  the  sputum  by  the  microscope,  only  two  are  characteristic 
— tubercle  bacilli  and  elastic  fibers.  Eosinophile  cells  were  at  one  time 
considered  by  Teichmiiller  as  a  sign  of  resisting  power  on  the  part 
of  the  patient,  but  such  a  claim  has  been  disproved  by  Turban  and 
others.  Polynuclear  and  mononuclear  levicocytes  are  abundant,  Lowen- 
stein  saying  that  tuberculous  sputum  consists  principally  of  pus  cells. 
J.  W.  A.  Wolff  asserts  that  polynuclear  leucocytes  speak  for  more  re- 
sisting power  in  the  patient  and  mononuclear  leucocytes  for  less,  but 
Lowenstein  denies  this.  In  this  connection,  it  will  be  remembered  that 
Arneth  considers  the  presence  of  polvTiuclear  leucocytes  in  the  blood 
evidence  of  greater  strength  than  when  mononuclears  are  found. 

Epithelial  cells  from  the  mouth  and  respiratory  tract,  alveolar  epi- 
thelium, partly  normal  and  partly  in  a  state  of  fatty  degeneration, 
leucocytes  with  pigment  and  myelin,  which  Buhl  considered  pathog- 
nomonic, will  all  be  found.  In  city  dwellers,  or  in  those  exposed  to 
much  smoke,   pigment  is  abundant,  and  can   even  make  the  sputum 


208    SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

black,  while  after  hemorrhage  brown  pigment  will  1)0  found  for  some 
time.  The  sputum  of  patients  moving  from  the  center  to  the  outskirts 
of  a  town  will  promptly  lose  in  pigment  content. 

Before  the  discovery  of  the  tubercle  bacillus  clastic  fibers  were  more 
commonly  sought  for  than  at  present,  and  it  is  to  be  regretted  that  their 
presence  is  now  so  rarely  determined,  as  they  speak  unfailingly  for 
lung-tissue  destruction,  and,  if  gangrene  or  abscess  can  ])e  excluded, 
for  tuberculosis,  especially  if  pus  cells  are  found  Avith  them.  Soko- 
lowski's  work  in  this  line  in  1877  is  suggestive.  Of  70  cases,  19  with 
marked  physical  signs  of  destruction  of  tissue  showed  elastic  fiber  in 
the  sputum,  in  18  on  the  first  or  after  repeated  examinations.  Of  11 
cases  with  symptoms  of  destruction,  but  good  general  condition  and 
no  fever,  all  showed  fibers.  In  the  remaining  40,  with  symptoms  of 
more  or  less  condensation,  the  fibers  were  found  in  the  majority.  In 
24  patients  with  only  slight  symptoms  they  were  found  in  8.  Of  the 
70  patients  they  were  present  in  75  per  cent.  Aufrecht  ('05)  quotes 
Dettweiler  and  Setzer,  who,  in  42  cases  where  careful  examination 
showed  only  infiltration,  found  fibers  in  34,  and  in  46  with  suspicion 
of  excavation  found  them  in  43,  and  in  22  with  positive  signs  of  cavity 
found  them  22  times,  or  in  90  per  cent  of  all  cases.  While  the  writer 
has  not  found  elastic  fibers  in  anything  like  so  large  a  percentage  of 
cases,  it  was  doubtless  due  to  lack  of  care  and  interest,  and  to  giving 
greater  attention  to  the  presence  of  bacilli. 

It  is  important  that  the  profession  be  impressed  with  their  real 
diagnostic  value  in  the  sputum.  They  appear,  to  quote  Fowler  ('98), 
as  single  or  multiple,  curled,  branching,  elastic  fibers,  forming  a  net- 
work, usually  with  traces  of  alveolar  arrangement,  and  with  a  pecul- 
iarly sharp  outline,  typical  of  such  fibers.  Fox  ('91)  Avarns  against 
mistaking  vegetable  fibers  for  elastic  fibers,  and  says  that  a  conclusion 
as  to  their  presence  could  not  be  drawn  unless  there  is  a  well-marked 
group  of  fibers,  having  AvcU-defined  outlines  and  the  peculiar  curves 
which  are  their  chief  characteristics. 

Osier  recommends  the  simple  method  of  Andrew  Clark,  of  pressing 
the  sputum  between  two  glass  plates  when  the  elastic  tissue  shows  as 
gray-yellow  spots,  which  can  be  picked  out  and  examined.  Sokolowski 
recommends  Fenwick's  method;  2  c.c.  of  water  and  of  sodium  hydrate 
are  added  to  an  equal  amount  of  sputum  and  boiled  for  three  or  four 
minutes.  This  destroys  everything  except  the  fibers,  which  can  then 
easily  be  gathered  and  examined.  Other  methods  are  mentioned  in 
detail  by  Czaplewski  ('91). 

Elastic  fibers  at  times  are  covered  with  a  peculiar  substance  soluble 
in  alkalies;  they  are  then  fairly  thick,  forked  threads  with  an  uneven 
granular  surface,  and  are  called  coral  fibers. 


SrBJECTI\'E   SYMPTOMS  209 

The  tnhenle  hacillus  is,  of  courpc,  the  only  ahsolutely  diagnostic 
sign  of  the  disease,  but  nnfortimately,  Avhile  a  positive  sign,  its  pres- 
ence being  absolute  proof,  its  absence  after  repeated  examinations  does 
not  exclude  tuberculosis.  Even  if  all  the  sputum  were  collected,  prop- 
erly treated,  centrifuged,  and  then  examined,  and  this  was  kept  up  for 
a  long  period  of  time,  it  would  be  impossible  to  deny  the  possible  tuber- 
culous nature  of  the  trouble.  At  the  same  time,  while  the  discovery  of 
the  bacillus  is  necessary  for  absolute  certainty,  the  physician  has  at 
his  disposal  many  methods  of  physical  diagnosis,  and  he  who  would 
wait  to  make  his  diagnosis  and  institute  treatment  until  he  found  the 
organisms,  would  rob  his  patient  of  precious  time  and  often  throw  away 
his  only  chance  of  cure.  In  cases  where  the  sputum  examination  is 
negative  and  in  which  certainty  is  important,  it  should  be  repeated  at 
very  frequent  intervals  and  with  every  precaution,  and  generally  such 
perseverance  will  be  rewarded. 

The  numljer  of  bacilli  in  the  sputum  was  at  one  time  supposed  to 
have  great  prognostic  value,  and  Gaffky  made  a  scale  of  numbers  corre- 
sponding to  the  number  of  bacilli  in  the  preparation,  which  is  still 
much  used : 

I, — One  to  four  bacilli  in  whole  preparation. 
II. — One  bacillus  on  average  in  many  fields. 
III. — One  bacillus  on  average  in  each  field. 
IV. — Two  to  three  bacilli  on  average  in  each  field. 

Y. — Four  to  six  bacilli  on  average  in  each  field. 
VI. — Seven  to  twelve  bacilli  on  average  in  each  field. 
VII. — Fairly  numerous  on  average  in  each  field.     (Brown  would  here 
put  twelve  to  twenty-five  in  each  field.) 
VIII. — Numerous  on  average  in  many  fields.     (Brown  would  put  about 
fifty  in  many  fields.) 
IX. — Very  numerous  on  average  in  many  fields.     (Brown  would  put 

one  hundred  or  more.) 
X. — Enormous  numbers. 

However,  the  substitution  of  mere  figures  for  a  definite  statement  of 
the  numbers  of  germs  does  not  tend  to  clearness,  and  it  would  be  better 
while  using  the  standard  given  to  note  the  exact  numbers  and  not 
simply  the  figures.  Browm's  modifications  seem  to  be  a  distinct  im- 
provement, but  Gaffky  makes  too  many  classes  between  IV  and  VII, 
2-5  and  5-10  and  10-25  being  better. 

While  it  is  useful  thus  to  record  the  number  of  germs  for  future 
reference,  the  conclusions  to  be  drawn  from  their  number  are  but  slight, 
bad  cases  frequently  showing  few  germs  and  acute  cases  none  at  all, 
while  at  times  in  mild  cases  they  may  be  found  in  large  numbers.     As 


210     SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

a  general  rule,  however,  rapidly  and  continually  increasing  numbers  of 
bacilli  in  the  sputum  speak  for  rapid  breaking  down  of  the  tissue,  and 
this  is,  therefore,  a  bad  sign,  while  a  gradual  and  continuous  decrease 
generally  goes  with  an  improving  case.  Moderate  and  temporary  fluc- 
tuations are  of  no  value  at  all.  If,  in  sputum  which  generally  shows 
few  bacilli,  there  is  a  small  caseous  mass,  the  preparation  may  be  a 
pure  culture  of  the  germ,  whereas  all  the  succeeding  specimens  will 
show  few  bacilli  or  none. 

Although  they  may  be  absent,  bacilli  are  found  in  the  sputum  of 
the  majority  of  patients.  Lawrason  Brown  ('03)  found  them  in  36 
per  cent  of  76  incipient  cases,  in  73  per  cent  of  164  moderately  ad- 
vanced cases,  and  in  94  per  cent  of  far-advanced  cases.  Turban  found 
them  in  38.4  per  cent  of  his  first-stage  cases,  89.8  per  cent  of  his  second- 
stage  cases,  and  98.8  per  cent  of  his  third-stage  cases. 

No  patient  can  be  pronounced  cured  in  whose  sputum  bacilli  can 
be  found,  as  they  are  the  infallible  evidence  of  an  open  lesion,  though  in 
a  few  cases  patients  who  are  clinically  well  will  expectorate  bacilli  for 
long  periods. 

The  tinctorial  qualities  of  the  bacillus  have  been  supposed  to  give 
us  some  idea  of  the  activity  and  virulence  of  the  germ  (short,  darkly 
staining  germs  being  supposed  to  come  from  very  active  cases;  long, 
thin,  beaded,  faintly  staining  ones,  the  so-called  degeneration  forms, 
showing  weakness),  but  after  a  good  many  years  of  sputum  work  I 
have  not  been  able  to  verify  such  a  supposition  further  than  that  severe 
acute  cases  do  seem  to  show  larger  numbers  of  short,  darkly  stained 
bacilli  and  no  degeneration  forms.  Degeneration  forms,  however,  have 
no  significance,  as  they  are  found  in  the  sputum  of  all  sorts  of  cases. 

Position  of  Bacilli. — The  germs  are  usually  scattered  through  the 
fields  between  the  cells,  and  where  they  are  scanty  they  are  more  apt 
to  be  found  in  the  streaks  of  mucus  produced  by  the  spreading.  They 
occur  either  singly  or  in  pairs  or  bundles,  and  when  multiple  show  a 
marked  tendency  to  lie  parallel  or  at  an  acute  angle  to  each  other.  At 
times  they  are  found  inside  the  leucocytes,  as  though  phagocytosis  were 
taking  place,  and  in  the  writer's  opinion  this  is  found  chiefly  in  severe 
cases,  but  the  work  of  Lowenstein  ('06)  and  Allen,  of  Saranac  ('07), 
who  kept  careful  records  in  many  cases,  does  not  support  such  a  view. 
Lowenstein  found  phagocytosis  in  about  eleven  per  cent  of  his  cases, 
Allen  in  eighty-two  per  cent  of  his,  the  former  agreeing  much  more 
nearly  with  the  wTiter's  experience  than  the  latter.  Lowenstein  found 
them  generally  in  the  leucocytes  with  one,  two,  or  three  nuclei,  which 
he  considers  the  younger  cells,  and  foiind  tliem  rarely  in  cells  with  four 
or  five  nuclei.  He  considers  them  commonest  in  very  chronic  cases, 
and  in  new  cases  tending  to  healing,  and  believes  they  precede  a  disap- 


SUBJECTIVE   SYMPTOMS  211 

pearance  of  the  I)acilli  from  the  sputum.  Allen,  on  the  other  hand, 
considers  them  of  little  value  in  prognosis. 

The  appearance  of  the  sputum  gives  no  hint  as  to  the  presence  or 
absence  of  bacilli.  At  times  a  mucoid,  almost  salivary  sputum  will 
show  numerous  germs,  while  very  commonly  a  profuse  purulent  sputum 
v/ill  show  none.  Aside  from  tubercle  bacilli  one  may  find  many  other 
forms  of  bacteria,  of  which  the  pneumococcus,  the  streptococcus,  the 
staphylococcus,  and  the  influenza  bacillus  are  the  most  prominent.  The 
latter  is  found  in  the  sputum  in  pure  culture,  in  many  cases  simulating 
tuberculosis,  Dr.  F.  T.  Lord,  of  Boston  ('05),  having  reported  a  num- 
ber of  interesting  cases  simulating  tuberculosis  which  were  apparently 
dependent  purely  on  a  chronic  grip  infection,  the  influenza  bacillus 
being  found  in  the  pure  culture  for  long  periods.  The  pneumococcus 
in  isolated  instances  is  very  common  in  sputum,  l)ut  at  times,  in  cases 
which  have  begun  with  pneumonia,  it  will  be  found  in  large  numbers 
for  a  long  time.  A  few  streptococci  or  staphylococci  are  not  at  all 
uncommon,  but  in  some  cases  the  streptococcus  will  be  found  in  such 
large  numbers  and  so  persistently,  even  when  the  sputum  is  properly 
collected  and  washed,  as  to  suggest  a  diagnosis  of  mixed  infection. 

That  such  a  mixed  infection  exists  or  can  be  proved  from  the  per- 
sistent and  abundant  presence  of  the  germ  in  the  sputum,  has  been  both 
vigorously  asserted  and  denied.  The  writer  believes  that  the  process  in 
the  lung  is  materially  affected  and  aggravated  by  the  coexistence  of  the 
streptococcus  with  the  tubercle  bacillus  in  the  areas  of  ulceration,  and 
that  it  is  responsible  for  many  of  the  symptoms  in  the  third  stage. 
Although  a  mixed  infection  can  exist  and  affect  the  course  of  the  case, 
too  many  physicians  make  a  diagnosis  of  mixed  infection  after  finding 
a  moderate  number  of  streptococci  in  the  sputum.  Such  an  opinion 
should  not  be  formed  unless  the  germ  is  found  in  large  quantities  and 
persistently  in  sputum  which  is  properly  collected  and  handled,  coming 
from  patients  with  clinical  evidence  of  pyogenic  infection.  The  dif- 
ficulties created  in  the  urine  by  the  smegma  bacillus  do  not  arise  in 
the  sputum,  but  the  technic  of  staining  the  bacillus,  while  simple  enough, 
demands  the  greatest  neatness  and  precision  in  the  work  (see  Diagnosis) 
if  the  results  are  to  be  reliable. 

While  anybody  can  find  bacilli  in  sputum  when  they  are  abundant,  it 
requires  great  skill  and  experience  and  the  most  precise  staining  methods 
if  they  are  to  be  found  in  the  cases  where  their  discovery  is  the  most 
important — i.  e.,  those  cases  where  the  germ  is  extremely  scanty. 

In  clinical  work  the  chemistry  of  the  sputum  need  not  be  dwelt  upon, 
except  that  its  organic  part  consists  of  glycogen,  sugar,  and  albumi- 
noid bodies  derived  from  the  white  cells,  especially  paraglobulin,  lecithin, 
and  peptones,  and  that  it  also  contains  phosphates  and  chlorids,  whose 


212    SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

loss  through  the  urine  in  this  disease  has  been  elsewhere  noted  (see 
Urinary  Symptoms).  Renk  has  demonstrated  a  nitrogenous  loss  of 
0.6  gm.,  which  equals  4.13  gni.  of  albumin,  or  5  per  cent  of  the  total 
nitrogen  consumption  of  the  consumptive.  This  albuminous  loss,  which 
Wanner  found  to  be  only  slight  in  bronchitic  sputum,  but  marked  in 
that  of  tuberculosis,  combined  with  a  loss  of  phosphorus  and  the  ehlo- 
rids,  is  a  severe  drain  on  the  system  in  old  cases  with  abundant  secreting 
cavities,  and  hastens  denutrition  and  exhaustion. 

The  reaction  of  the  sputum  is  usually  alkaline,  unless  bacterial  action 
in  the  cavity  has  produced  an  acid  reaction,  and  as  the  differential  stain 
fails  in  acid  sputum,  cases  where  a  sputum  examination  is  negative 
should  suggest  a  test  of  its  reaction,  and  its  correction,  if  acid. 

Hemorrhage. — So  alarming  a  symptom  as  pulmonary  hemorrhage 
compels  attention,  and  from  the  days  of  Hippocrates  has  occupied  a 
prominent  place  among  the  symptoms  of  this  disease.  The  father  of 
medicine,  noticing  the  development  of  phthisis  after  a  hemorrhage  oc- 
curring in  apparently  healthy  subjects,  very  natiirally  concluded,  with 
the  methods  of  investigation  at  his  disposal,  that  phthisis  was  the  result 
of  the  hemorrhage,  and  spoke  of  phthisis  ah  hcemaptoe,  and  the  power 
of  authority  in  medicine  and  the  slow  development  of  medical  knowl- 
edge is  well  shown  when  we  recall  that  this  view,  promulgated  be- 
fore the  time  of  Christ,  was  generally  accepted  well  into  the  last 
century,  and  although  Laennec  and  Louis,  of  France,  in  the  first 
half  of  the  nineteentli  century  recognized  and  taught  the  error  of 
this,  it  had  so  distinguished  a  defender  as  the  great  Niemeyer  as  late 
as  1870. 

While  there  are  various  conditions  which  can  produce  a  discharge 
of  blood  from  the  mouth,  and  thus  simulate  a  pulmonary  hemorrhage, 
as,  for  exaiuple,  heart  disease,  carcinoma,  hemophilia,  arteriosclerosis, 
vicarious  menstruation,  hysteria,  aneurysm,  bleeding  gums,  nasal,  pha- 
ryngeal, laryngeal,  or  gastric  lesions,  the  great  majority  of  all  hemor- 
rhages are  dependent  on  tuberculosis  of  the  lungs.  In  this  connection 
the  well-known  statistics  of  Sticker  as  to  hemorrhage  in  the  ranks 
of  the  German  army  are  very  instructive.  Of  480  cases  of  hemor- 
rhages, either  without  known  cause  or  following  "  colds,"  221  were 
tuberculous,  196  probably  so  (86.6  per  cent).  Of  379  cases  of  hemor- 
rhage resulting  from  overexertion  in  military  maneuvers,  g^'mnastics, 
singing,  blowing  wind  instruments,  trauma,  and  the  like,  282,  or  74.4 
per  cent,  were  tuberculous.  So  marked  is  the  causal  relation  that  See 
('84)  says,  "  aside  from  infectious  diseases,  hemophilia,  and  acute  in- 
fections of  the  lungs  (pneumonia,  abscess,  gangrene)  ...  we  only 
know  of  two  real  causes  of  hemoptysis — heart  disease  and  pulmonary 
tuberculosis,"  and  with  the  advance  of  modern  diagnostic  and  clinical 


SUBJECTIVE   SYMPTOMS  213 

methods  it  is  dail}^  more  evident  that  in  a  case  of  pulmonary  hemorrhage 
the  evidence  must  be  very  strong  to  support  any  other  diagnosis  than 
that  of  tuberculosis. 

The  pathologic  conditions  antecedent  to  hemorrhages  var}^  in  early 
and  late  cases.  In  early  cases  several  hypotheses  have  been  advanced  to 
exphrin  bleedings  occurring  before  there  is  destruction  of  tissue.  A 
localized  hyperemia  of  the  pulmonary  tissue  has  been  suspected,  and 
Flint  ('75)  cites  a  most  suggestive  case  and  autopsy  which  seems  to  jus- 
tify this  as  a  probable  cause,  and  Anders  ('07)  considers  tliat  the  influ- 
ence exerted  by  violent  or  long  physical  exercise  in  the  production  of 
hemoptysis  justifies  this  view.  However,  it  is  prol)al)le  that  the  more 
ordinary  cause  is  the  weakening  or  erosion  of  small  blood-vessels  l)y 
the  growth  into  them  of  tubercles,  or,  as  is  well  put  by  See:  "We 
must  recall  that  the  branches  of  the  pulmonary  artery  are  terminal 
branches  ...  if  the  caliber  of  one  of  these  arteries  is  lessened  as  a 
result,  for  example,  of  a  perivascular  tubercle,  and  protrudes  into  the 
lumen,  the  blood-pressure  is  raised  at  the  narrow  part,  and  a  rupture 
follows." 

The  hemorrhage  can  only  cease  by  the  occlusion  of  the  bleeding 
vessel  by  a  thrombus  filling  the  cavity,  and  until  this  is  firm  the  hemor- 
rhage will  continue,  hence  the  great  need  of  absolute  rest  and  quiet 
to  favor  the  occlusion  of  the  l)leeding  point. 

Early  lieniorrhages  are  always  venous,  and  therefore,  since  pulmo- 
nary venous  blood  is  aerated,  are  bright  red.  In  later  stages  hemorrhages 
arise  from  the  vessels  of  the  lung,  usually  a  pulmonary  artery,  chiefly  in 
cavities,  and  the  blood  is  dark.  The  connective  tissue  of  the  advantitia 
being  more  resistant  to  the  eroding  effects  of  the  destructive  process, 
the  blood-vessels,  generally  of  moderate  size,  are  dissected  out  and  stand 
out  in  the  walls  of  the  cavity  or  cross  it.  On  these  unsupported  vessels 
small  saccular  or  fusiform  aneurysms  form,  and,  generally  as  a  result 
of  raised  blood-pressure,  burst,  giving  rise  to  the  large  and  fatal  hemor- 
rhages of  late  phthisis.  This  method  of  hemorrhage  production  being 
open  to  demonstration  by  autopsy  is  the  best  established  of  all,  but  in 
some  old  cavity  cases  it  seems  probable  that  hemorrhage  can  result  from 
the  oozing  of  the  granulations  which  line  the  walls.  The  relation  of 
overexertion  to  the  occurrence  of  pulmonary  hemorrhage  justifies  the 
belief  that  a  large  number  of  cases  of  hemorrhage  are  brought  about 
by  an  undue  rise  in  I)lood-pressure,  and  every  physician  can  remember 
many  cases  which  followed  the  lifting  of  weights,  straining  at  stool, 
running  upstairs,  etc.,  but,  although  the  condition  of  patients  just  after 
a  hemorrhage  makes  it  difficult  to  study  their  blood-pressure  carefully 
at  such  times,  a  large  percentage  of  cases  will  show  a  low-tension  pulse 
before  as  well  as  after  the  hemorrhage,  and  Otis  ('07),  in  18  cases  at 


214  SYMPTOMATOLOGY    OF    PULMONARY   TUBERCULOSIS 

the  Rutland  Sanatorium,  found  the  pressure  normal  or  below  normal 
in  all  but  one. 

The  frequency  of  hemorrhage  in  tuberculosis  has  been  variously 
estimated  between  30  per  cent  and  80  per  cent;  De  Renzi  ('94)  gives  it 
as  one  third  to  two  thirds,  Fox  ('91)  as  5-t  per  cent,  Aufrecht  ('05) 
as  26.4  per  cent,  Williams  ('87)  as  57  per  cent,  Walsh  ('71)  as  81 
per  cent,  these  various  estimates  depending  probably  on  the  class  of 
patients  studied  by  the  different  authors.  From  40  to  60  per  cent  would 
be  a  fair  estimate.  The  immediate  cause  of  hemorrhage  in  early  cases 
is  not  always  determinable;  often  a  man  in  apparently  perfect  health 
and  at  rest  will  suddenly  bring  up  a  mouthful  of  bright,  foamy  blood 
without  warning  of  any  sort.  More  commonly,  however,  the  cause  is 
overexertion,  such  as  athletics,  lifting  weights,  running  upstairs,  strain- 
ing at  stool,  blows  on  the  chest,  unduly  hard  percussion,  or,  in  short, 
anything  which  raises  blood-pressure  or  produces  trauma.  Excitement, 
worry,  or  temper  can  act  in  the  same  way,  and  the  sight  of  one  patient 
bleeding  will  not  infrecpiently  start  a  hemorrhage  in  another  patient. 

Barometric  or  other  metcorologic  conditions  have  an  undeniable 
etfect  in  producing  hemorrhages,  though  it  does  not  seem  that  this  has 
been  sufticiently  dwelt  on  by  A\Titers  on  the  subject.  It  is  certain  that 
everyone  who  has  handled  numerous  cases  of  tuberculosis  has  often 
been  struck  with  the  occurrence  of  several  cases  of  hemorrhage  within 
a  day  or  so,  and  ascril)able  apparently  only  to  weather  conditions. 

While  the  writer  has  not  made  a  close  study  of  meteorology,  he  has 
noticed  that  close,  damp,  hot  spells  with  a  low  barometer  seem  to  be 
the  time  when  many  cases  of  hemorrhages  are  apt  to  occur,  and  that 
this  bunching  is  nnich  less  common  in  winter.  Thus,  in  the  practice 
of  Dr.  W.  L.  Dunn,  in  the  summer  of  1907,  sixteen  hemorrhages 
occurred  among  his  patients  in  one  week.  While  it  is  impossible  at 
present  to  prove  such  a  causal  relation,  it  is  certain  that  the  majority 
of  clinicians  have  noted  such  an  effect  of  weather  conditions. 

The  premenstrual  period,  during  which  there  is  a  systemic  plethora, 
has  a  distinct  effect  in  producing  hemorrhage,  and  female  patients  of 
a  hemorrhagic  tendency  come  to  dread  this  time.  In  patients  who  have 
ceased  to  menstruate,  any  undue  susceptibility  to  hemorrhage  has  not 
been  noted,  but  instances  of  vicarious  hemorrhage  as  a  substitute  for  a 
missed  menstrual  period  or  cured  bleeding  hemorrhoids  are  on  record. 

In  patients  whose  appetite  is  very  large,  and  in  whom  a  condition 
of  plethora  is  created  by  hypernutrition  and  rest,  not  at  all  a  rare  thing 
in  sanatoria,  it  has  seemed  that  hemorrhage  is  more  common  than  in 
others  less  fully  nourished ;  those  patients  who  have  fattened  and  become 
ruddy  rapidly  under  outdoor  treatment  quite  frequently  show  some 
bleeding. 


SUBJECTIVE   SYMPTOMS  215 

If  sex  has  an}-  influence  on  hemorrhage,  as  Louis  taught,  it  is  not 
very  great,  although  there  is  a  slight  preponderance  of  hemorrhages  in 
women.  Anders  (07),  in  589  cases,  found  that  liability  to  hemorrhage 
appeared  at  an  earlier  period  in  women  than  in  men. 

There  does  not  seem  to  be  any  special  time  of  the  day  which  favors 
the  occurrence  of  hemorrhage,  though  the  disturljance  of  the  doctor's  sleep 
by  night  hemorrhages  is  apt  to  cause  him  to  think  them  more  common 
in  the  night  time.  The  season  of  the  year  has  a  distinct  influence.  In 
the  writer's  experience  the  spring  months  show  a  preponderance  of 
hemorrhages,  and  as  this  is  the  time  when  a  tuberculous  patient  is 
best  nourished,  it  may  possibly  be  explainable  on  the  grounds  of  plethora. 
Thompson  ('T9)  considers  tliem  commonest  in  the  summer  heat,  and 
Anders  ('07)  found  them  most  common  in  the  spring  and  summer 
nuiuths,  and  ascribed  them  to  the  enervating  effects  of  heat  and  the 
influence  of  marked  oscillations  of  heat  and  humidity  during  the  spring 
months,  but  Gabrilowitsch  ('99),  in  Finland,  found  hemorrhages  most 
frequent  in  March  and  October,  and  none  occurring  between  April  and 
July. 

Hereditij,  according  to  Fox  ('91),  ])lays  some  part,  those  of  his 
patients  who  had  a  marked  family  history  of  tuberculosis  showing  a 
greater  tendency  to  hemorrhage. 

Age  has  a  marked  influence,  hemorrhages  being  extremely  rare  in 
infancy  and  uncommon  in  childhood,  and  increasing  in  frequency  witli 
puberty,  most  common  between  twenty  and  twenty-five,  and  after  forty- 
five  becoming  less  common.  They  are  rare  in  old  age.  Of  Aufrecht's 
cases  ('05),  forty  per  cent  were  between  twenty  and  twenty-five,  and 
83  of  Anders's  197  cases  were  between  twenty  and  thirty,  and  6'2  between 
thirty  and  forty  ('07). 

The  stage  of  the  trouble  bears  some  relation  to  the  frequency  of 
hemorrhage.  It  may  be  an  initial  symptom,  nine  per  cent  of  Reiche's 
cases  being  of  this  sort;  in  abortive  cases  it  is  often  the  only  symp- 
tom. While  it  may  occur  at  any  time  during  the  course  of  the 
disease,  the  writer  has  found  hemorrhage  most  common  in  relatively 
advanced  cases,  and  Fox  ('91)  agrees  wath  this  view,  but  quotes  the 
first  Brompton  report,  in  which  seventy-two  per  cent  of  the  hemorrhages 
occurred  before  softening,  and  Williams  also  believes  that  the  first  hem- 
orrhage is  aj)!  to  occur  early  in  the  trouble.  Thompson  ('79)  con- 
siders bleeding  most  frequent  in  the  second  stage,  with  ulceration,  437 
out  of  1,000  of  his  cases  occurring  at  this  time.  Possibly,  however, 
careful  inquiry  into  the  past  history  of  the  patient  might  reveal  pre- 
vious slight  hemorrhages  in  many  cases  seen  first  in  a  more  advanced 
state. 

Fatigue  is  a  common  cause,  ])ossibly  because  fatigue  generally  implies 


216  SYMPTOMATOLOGY  OF   PULMONARY  TUBERCULOSIS 

overexertion  and  raised  blood-pressure;  certainly  hemorrhages  seem  to 
be  very  common  during  or  just  after  long  railway  journeys. 

Clinical  Picture. — Quite  frequently  a  hemorrhage  is  preceded  by  no 
warning  symptom;  the  patient  suddenly  feels  something  in  his  throat, 
spits  it  up,  and  is  horrified  to  find  that  it  is  blood.  More  generally, 
however,  there  is  a  pricking  in  tlie  throat,  a  short  cough,  a  salty  taste 
in  the  mouth,  a  sense  of  weight  and  oppression  or  tightness  in  the  chest, 
while  not  infrequentlv  there  will  be  a  sore  spot  in  the  lung  for  a  few 
days  preceding  a  hemorrhage,  or  a  feeling  of  tightness,  pain,  and  oppres- 
sion, and  many  patients  can  predict  a  hemorrhage  which  the  doctor  is 
far  from  anticipating,  so  that  physicians  should  never  neglect  any  such 
"  feelings  "  on  the  part  of  tlieir  patients. 

A  premonitory  streaking  of  the  sputum  with  traces  of  blood  will,  in 
moderately  advanced  cases,  often  precede  the  bleeding  for  some  days, 
and  gives  us  useful  warning,  for  blistering  over  the  site  of  congestion 
will  unquestionably  have  good  effect  in  some  of  these  eases.  The  amount 
of  blood  lost  may  vary  from  a  slight  streaking  of  the  sputum,  or  a 
faint,  pinkish  staining  to  any  degree  of  mixed  sputum  and  blood,  up  to 
mouthfuls  of  pure  blood ;  but  a  hemorrhage  does  not  generally  exceed 
one  half  to  one  pint,  though  in  old  cavity  cases  enough  blood  may  come 
up  to  kill  the  patient  at  once  by  syncope. 

A  correct  estimate  of  the  quantity  is  difficult,  if  not  impossible,  the 
patient  and  his  friends  generally  being  terrified,  the  blood  often  being 
received  into  water  in  a  basin  or  slop  jar,  and  increased  in  bulk  by 
frotliiness  and  greatly  magnified  by  alarm.  However,  while  a  single 
hemorrhage  is  rarely  as  large  as  a  patient  supposes,  the  repetitions  can 
bring  the  amount  lost  in  twenty-four  hours  up  to  a  quart  or  more,  and 
it  is  surprising  what  large  amounts  patients  can  continue  to  lose,  day 
after  day,  without  succumbing.  Smirnow  recently  ('07)  reported  a 
case  in  which  ninety-seven  ounces,  by  careful  m.easurement,  were  lost  in 
three  days,  the  patient  recovering.  The  majority  of  hemorrhages  are 
probably  less  than  one  ounce,  the  figure  given  by  West   ('02). 

The  color  of  the  blood  in  early  cases  is  bright  red,  and  is  at  this 
time  generally  combined  witli  air,  so  as  to  be  foam)^  and  is  mixed  with 
much  saliva  and  sputum.  In  advanced  cases  it  can  come  up  in  gurgling 
gulps,  and  is  darker,  since  it  comes  from  the  arteries,  and  by  clotting 
in  the  larger  bronchi  often  produces  severe  dyspnea.  If  the  hemorrhage 
lasts  for  some  days  the  later  blood  is  clotted  and  dark,  but  should  not 
easily  be  mistaken  for  stomach  blood.  By  degrees  the  blood  clots  lessen, 
sputum  begins  to  reappear,  although  at  first  badly  blood-stained.  Grad- 
ually, however,  it  resumes  its  normal  color,  and  in  a  few  days,  if  the 
hemorrhage  does  not  repeat  itself,  no  more  traces  can  be  found.  When 
pneumonia  sjipervenes,  there  occurs,  generally  on  the  third  or  fourth 


SUBJECTIVE   SYMPTOMS  217 

day,  a  sudden  extreme  rise  of  temperature,  which  continues  without 
remission  until  it  clears  up,  but  if  dissemination  follows  the  pneumonia, 
the  temperature  persists.  T?ie  temperature. gives  no  warning  of  impend- 
ing hemorrhage,  but,  except  in  very  slight  cases,  rises  moderately  within 
a  few  hours  after  its  occurrence.  If  the  loss  of  blood  is  very  large,  there 
will  occasionally  be  a  drop  of  temperature,  but  within  the  first  twelve 
to  twenty-fours  hours  there  will  always  be  a  rise,  which,  if  no  compli- 
cations develop,  gradually  disapi)ears. 

The  physical  signs  of  hemorrhage  are  very  unsatisfactory.  The  most 
careful  auscultation  may  fail  to  show  the  site  of  the  bleeding,  and  in 
early  hemorrhages  the  most  thorough  examination  will  often  fail  to  show 
any  signs  of  pulmonary  trouble,  so  that  the  absence  of  demonstrable 
lesions  should  never  lead  one  to  declare  that  a  hemorrhage  did  not  come 
from  the  lungs. 

If  the  process  is  already  known  to  exist  in  the  lung,  it  may  even 
then  be  impossible  to  find  any  signs  of  effused  blood,  though  generally 
one  will  find  large  or  medium  moist  rales  in  the  sternoclavicular  angle, 
or  second  or  third  interspace,  on  the  affected  side,  gradiially  diminish- 
ing downward  and  not  infrequently  discoverable  at  the  base  as  well. 
This,  however,  does  not  justify  a  statement  that  the  blood  originated  at 
the  point  where  the  rales  are  heard,  as  the  fluidity  of  the  blood  allows 
it  to  travel  rapidly,  so  that  not  infrequently  one  can  get  moisture  on 
the  sound  side;  but  unless  the  hemorrhage  be  followed  by  rapid  dis- 
semination, the  moisture  disappears  in  two  or  three  days. 

In  hemorrhages  of  any  considerable  size  the  information  to  be  gained 
by  physical  examination  is  too  slight  to  justify  one  in  favoring  a  recur- 
rence of  bleeding  by  the  necessary  manipulations  of  a  physical  examina- 
tion. Percussion  should  in  no  case  be  made,  and  except  for  a  light  aus- 
cultation of  the  easily  accessible  anterior  thorax  the  lungs  should  not  be 
examined  until  the  sputum  begins  to  clear  up. 

Hemorrhages  may  be  single  and  never  recur,  and  every  physician  at 
times  gets  histories  of  such  cases.  These  are  the  "  abortive  cases," 
which,  until  recent  years,  have  been  overlooked,  but  where  autopsies 
long  afterwards  show  old  healed  tuberculous  foci.  A  gentleman,  now 
nearly  sixty  years  of  age,  while  a  slender  boy  of  sixteen  was  rather  run 
down  and  below  par,  and  had  a  slight  hemorrhage,  for  which  he  was 
sent  to  the  country  for  a  year,  and  has  ever  since  lived  in  a  large  city 
in  perfect  health.  If,  however,  a  close  study  were  made  of  many  of 
these  patients  in  their  after  life,  a  number  would  show  the  development 
of  tuberculosis  at  a  later  date.  Such  a.  case  is  reported  Ijy  See  ('84). 
An  Italian  gentleman,  who  had  a  hemorrhage  at  twenty-one,  was  per- 
fectly well  until  forty-four,  wlien  he  developed  a  cough  and  showed 
signs  of  apical  tuberculosis.     Unfortunately,  many  of  these  patients  do 


218    SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

not  consult  a  doctor,  or  if  they  do  tliey  are  too  often  assured,  after  a 
superficial  examination,  that  the  bleeding  was  of  no  importance,  and  go 
away  with  a  dangerous  sense  of  security. 

Such  patients  may  either  be  in  perfect  health  at  the  time  or  be 
somewhat  "  run  down  and  below  par,"  with  possibly  a  slight  cough.  In 
any  case,  all  such  should  be  considered  tentatively  tuberculous,  and  every 
diagnostic  measure  be  used  to  reach  certainty,  and  if  a  diagnosis  cannot 
be  made,  the  after  course  of  the  patient  should  be  followed  with  care. 

Tliere  is  another  class  of  patients  in  which  but  one  hemorrhage 
occurs,  where  one  large  hemorrhage  is  followed  by  the  development  of 
an  acute  bronchopneumonic  phthisis  from  a  general  dissemination  of 
bacilli  through  the  lung  by  the  blood,  which  at  times  shows  the  germ 
abundantly.  Such  are  the  cases  developing  unexpectedly  in  unusually 
athletic  young  men,  in  tlie  midst  of  perfect  health,  and  usually  going 
on  to  a  rapidly  fatal  ending.  The  large  majority  of  tuberculous  hemor- 
rhages, however,  are  sure  to  recur  at  some  more  or  less  remote  time, 
though  if  one  could  get  statistics  of  all  the  cases  referred  to  above  in 
which  there  was  one  hemorrhage,  the  trouble  then  aborting,  this  majority 
would  doubtless  be  greatly  reduced. 

After  a  hemorrhage  begins  most  patients  will  have  several  l)lood- 
spittings  during  the  next  few  da3's,  and  in  not  too  incipient  cases  the 
blood-spitting  may  occur  several  times  a  day  for  as  much  as  six  weeks, 
and  yet  be  followed  by  improvement,  and  it  is  surprising  to  see  what 
large  amounts  of  blood  a  patient  can  lose  without  suffering  more  than 
a  slight  anemia,  and  with  final  recovery. 

The  nervous  system,  even  in  the  most  phlegmatic,  undergoes  a  great 
shock  at  the  first  one  or  two  hemorrhages,  but  familiarity  breeds  con- 
tempt, and  after  a  few  recurrences  a  patient  looks  upon  a  hemorrhage 
with  remarkable  coolness. 

Recurrences  may  be  either  at  long  intervals,  generally  accompanied 
by  a  relatively  favorable  condition  in  the  interim,  or  there  may  be  a 
rapidly  repeating  series  of  hemorrhages  producing  an  acute  dissemina- 
tion, hastening  a  fatal  termination,  or  producing  a  severe  and  fatal 
anemia.  Such  patients  continue  to  bleed,  with  short  intermissions  of  a 
day  or  so,  for  two  months,  gradually  losing  strength,  becoming  anemic, 
and  wasting  till  life  is  ended.  In  these  cases  it  is  impossible  to  decide, 
if  there  are  no  great  signs  of  spread  of  the  trouble,  whether  the  patient 
can  finally  check  the  bleeding  and  recover  or  not,  and  the  doctor  and 
family  are  kept  alternately  between  hope  and  despair  for  weeks. 

Where  large  cavities  do  not  exist,  frequently  recurring  hemorrhages 
speak  for  a  rapidly  disseminating  process  in  the  lungs,  with  the  forma- 
tion of  tubercle  and  destruction  of  tissue.  In  old  cavity  cases  there 
may  be  long  periods  in  which  the  patient  brings  up  gray  cavity  sputum, 


SUBJECTIVE   SYMPTOMS  219 

evenly  stained  pink,  owing  to  the  oozing  of  blood  from  the  granulations 
lining  the  cavity,  and  such  pink  sputum  often  precedes  a  hemorrhage. 

The  results  of  hemorrhage  are  much  less  severe  than  the  alarming 
nature  of  the  symptoms  would  lead  one  to  expect.  In  early  cases  the 
immediate  results  are  generally  negative,  the  patient  feeling  no  change 
of  any  sort  in  his  condition,  barring  the  nervous  shock.  In  rather  more 
advanced  cases  the  patient,  relieved  of  a  sense  of  tiglitness  and  oppres- 
sion in  his  chest,  the  pain  removed,  and  his  trying  dry  cough  changed 
to  an  easy,  loose  one,  feels  in  ewry  way  much  better,  and  not  a  few 
such  cases  are  not  only  thus  subjectively  improved,  but  date  their  recov- 
ery from  the  beginning  of  the  hemorrhage.  Whether  this  is  due  to  a 
germicidal  or  antitoxic  effect  of  the  blood  senmi  which  floods  the  lung, 
or  not,  is  unknown,  but  apparently  the  local  action  of  the  blood  on  the 
lung  can  be  favorable,  unless  it  serves  to  spread  bacteria  through  its 
tissues..  At  one  time  it  was  held  by  Niemeyer  that  the  blood,  by  its 
presence  in  the  lungs,  produced  an  inflammation  harmful  in  itself,  and 
precedent  to  tuberculosis,  but  experiments  (See)  have  shown  that  pure 
blood,  free  from  germs,  can  be  injected  into  the  lung  and  absorbed  there 
Avithout  any  inflammatory  effects.  Flint  ('75)  noted  more  recoveries 
in  his  hemorrhagic  cases  than  in  those  not  having  hemorrhages,  and 
believed  that  in  tlie  majority  of  cases  their  effect  was  good.  This  can, 
in  some  degree,  be  ascribed  to  the  fact  that  so  alarming  a  symptom  is 
apt  to  make  even  the  most  heedless  patient  careful  and  obedient  so  that 
better  results  can  be  gotten  from  his  case. 

In  very  advanced  cavity  cases,  liowever,  the  effects  of  hemorrhage 
are  generally  disastrous,  even  where  tlie  bleeding  is  not  sufficient  to  kill 
at  once,  which  is  the  end  in  a  certain  number  of  cases.  Cornet  ('07) 
quotes  Brehmer,  Wolff,  and  Strieker,  who  found  0.15  per  cent  of  such 
sudden  deaths  in  pulmonary  hemorrhage. 

A  typical  instance  was  that  of  a  middle-aged  lady,  who  had  advanced 
and  incurable  plithisis,  with  a  large  excavation  in  the  left  lung,  and 
who  Avintered  in  Asheville  for  several  years  with  great  comfort,  though 
without  any  prospect  of  cure.  AVithout  having  had  premonitory  symp- 
toms of  any  kind,  she  awoke  one  morning  at  the  usual  hour,  sat  up  in 
bed,  and  began  to  speak  to  her  sister  across  the  room,  when  suddenly 
a  flood  of  blood  burst  from  her  mouth  and  she  fell  back  dead,  doubtless 
from  cerebral  anemia  and  syncope.  Such  an  end  is  painless  and  instan- 
taneous; but,  on  the  otlier  hand,  death  by  suffocation  from  a  large  hem- 
orrhage is  very  painful ;  the  air  hunger,  the  gurgling  blood  in  the  throat, 
the  spasmodic  efforts  at  breathing,  and  blood  over  everything,  making  a 
terrible  and  never-to-l)c-forgotten  picture,  which,  fortunately,  is  not 
common.  At  times  only  a  little  blood  appears  at  the  lips,  most  of  it 
being  retained  in  the  cavity  and  the  l)ronchi.     The  result,  however,  is 


220     SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

equally  fatal.  While  sudden  death  of  this  type  is  rare,  the  more  remote 
dangers,  exsanguination,  exhaustion,  and  pneumonia,  with  or  without 
acute  softening  and  dissemination  of  the  process,  are  more  common. 

The  following  case  is  a  good  example  of  pneumonia,  with  rapid 
dissemination : 

A  gentleman  of  middle  age,  with  a  very  small  cavity,  nearly  dry  and 
shrinking,  who  apparently  was  going  on  toward  a  satisfactory  arrest 
of  his  trouhle,  and  who  had  almost  no  symptoms  of  any  sort,  hegan  to 
show  slight  hlood  streakings  in  his  sputum,  which  rapidly  increased  to 
copious  discharges,  continuing  for  several  days,  and  due  i)rohahly  to  the 
erosion  of  a  small  miliary  aneurysm.  Suddenly  the  temperature  went 
up,  pneumonia  developed,  followed  by  rapid  acute  softening,  and  the 
man  was  dead  in  ton  days. 

In  all  hemorrhagic  cases  a  sudden,  undue  rise  of  temperature  on 
the  second  or  third  day  should  excite  suspicion  of  pneumonia.  If  pneu- 
monia develops,  the  temperature  will  continue  high,  pains  in  the  side, 
though  not  always  present,  will  generally  develop,  and  physical  signs 
appear.  Such  a  pneumonia  may  be  either  a  broncliopneumonia  or  a 
lobar  pneumonia  due  to  the  pneumococcus  which  is  present  in  the  lungs, 
and  which  is  probably  stimulated  to  grow  by  the  blood  serum  thrown 
out,  and  from  these  the  patient  often  recovers  very  well;  or  it  may  be 
an  acute  tuberculous  pneumonia,  due  to  the  l)acillus,  which  has  a  uni- 
formly fatal  termination.  Again,  the  fatal  result  may  be  due  to  exhaus- 
tion and  to  exsanguination.  Such  a  case  was  that  of  a  young  man 
recently  brought  from  Colorado  Springs  to  Asheville  on  account  of  fre- 
quently recurring  hemorrhages.  He  at  first  seemed  to  improve  a  little, 
but  after  a  few  weeks  the  hemorrhages  began  to  recur  again,  and  he 
would  have  a  nund^er  of  small  or  moderate-sized  ones  during  several 
days,  with  free  intervals  of  several  days  between.  No  marked  dissem- 
ination occurj'ed,  but  although  he  lost  no  very  large  quantity  of  blood 
at  any  one  time,  the  steady  drain  on  his  blood-making  organs  and  on 
his  vitality  was  too  great ;  he  grew  paler  and  paler,  and  more  and  more 
exhausted,  and  finally  died  from  these  causes  alone. 

Quite  a  frequent  result  of  hemorrhage  is  a  moderate  degree  of  dis- 
semination of  trouble  into  hitherto  healthy  surrounding  areas,  and  it 
is,  therefore,  necessary  to  make  a  most  careful  examination  when  the 
patient  has  recovered  from  the  bleeding  to  see  if  any  such  dissemination 
has  occurred. 

The  diagnosis  in  most  cases  is  easy,  but  at  times  is  accompanied  by 
considerable  difficulty.  It  is  too  commonly  the  habit  of  the  profession 
to  say  that  a  slight  hemorrhage  came  from  the  nose  or  the  throat  in  order 
to  quiet  anxiety,  a  practice  that  cannot  be  condemned  too  emphatically. 
Even  the  most  nervous  patient  can  tactfully  be  made  to  realize  to  what 


SUBJECTIVE  SYMPTOMS  221 

the  hemorrhage  is  due  without  heing  unduly  ahirmed ;  and  even  were 
it  impossible  not  to  alarm  the  patient,  it  would  be  much  more  desirable 
to  do  so  than  to  keep  him  in  ignorance  of  the  truth,  when  that  igno- 
rance so  often  means  loss  of  the  best  chance  of  recovery. 

In  certain  j)atients  the  possibility  of  hysterical  blood-spitting  must 
be  kept  in  mind,  and  one  should  be  certain  that  the  patient  is  not  pro- 
ducing blood  in  order  to  create  sympathy.  A  few  people  can  uncon- 
sciously, in  their  sleep,  suck  their  gums,  and  if  these  are  unhealthy  they 
can  Avake  up  to  find  bloody  saliva  in  their  mouths,  but  here,  again,  care- 
ful examination  should  remove  any  difficulty.  In  doubtful  cases,  the 
nose,  mouth,  throat,  and  larynx  sbould  be  examined  carefully  under 
the  most  favorable  conditions  to  exclude  possible  broken  blood-vessels 
in  these  regions;  the  heart  should  be  gone  over  carefully  to  exclude 
mitral  stenosis  or  any  other  cardiac  conditions  antecedent  to  hemor- 
rhage. Babeock  would  distinguish  blood  coming  from  above  the  glottis 
by  tbe  fact  tliat  it  is  not  accompanied  by  cough,  while  he  believes  that 
pulmonary  hemorrhage  invariably  is  accomjjanied  by  cough. 

If  there  is  any  dou])t  as  to  a  possible  hematemesis,  tbe  expectorated 
blood  should  be  examined  ocularly  and  microscopically  and  as  to  its 
reaction,  especially  as  quite  often  after  hemorrhage  patients  will  vomit 
blood  which  came  from  tbe  lungs  and  was  swallowed.  But  hematemesis 
can  at  times  present  insuperable  difficulties  of  diagnosis,  so  keen  an 
observer  as  Graves  having  said :  "  You  are  told  gravely  that  you  can 
distinguish  blood  discharged  from  the  stomach  from  that  which  is 
discharged  from  the  lungs  by  the  differences  of  its  color  and  con- 
sistence, and  the  presence  or  absence  of  air  buljbles.  No,  gentlemen, 
you  cannot." 

In  some  cases  it  is  possible  to  get  a  previous  history  of  tender  spots 
in  the  stomach,  hyperchlorhydi'ia,  d3'^spepsia,  etc.,  but  where  blood  comes 
from  a  gastric  varix,  or  from  an  aneurysm  of  the  ])ulmonarv  arterv,  a 
diagnosis  is  impossil)le.  Theoreticallv,  stomach  blood  sliould  be  unmixed 
with  air,  and  acid  in  reaction,  if  not  too  aljundant;  one  should  also  be 
able  to  find  food  remains,  and  it  should  be  followed  by  tarry  stools,  etc., 
but  such  distinctions,  while  very  easy  to  note,  are  by  no  means  alwaAS 
as  easy  to  discover  clinically.  The  brightness  of  color  of  the  blood  is 
of  no  assistance,  blood  from  the  lungs,  if  from  a  ])ulnionary  vein  or 
bronchial  artery,  being  bright  red  instead  of  dai'k. 

Hemorrhage  due  to  heart  disease  should  not  give  trouble  to  anyone 
habiiuated  to  carefully  going  over  every  detail  of  his  case,  ])ut  not  infre- 
(luently  a  diagnosis  of  tubei'culosis  of  the  lungs  is  made  when  mitral 
stenosis  alone  exists. 

Hemorrhage  from  a  nontul)erculous  lung — a  vicarious  menstruation 
— is  on  record.     The  writer  has  never  seen  such  a  case,  nor  a  pui'ely 


222  SYMPTOMATOLOGY   OF   PULMONARY  TUBERCULOSIS 

hysterical  liemorrliage,  although  several  authentic  cases  are  on  record. 
It  must  present  great  difficulties  of  diagnosis.  However,  it  cannot  too 
often  be  insisted  on  that  while  one  should  not  jump  to  the  conclusion 
that  every  hemorrhage  is  an  evidence  of  pulmonary  tuberculosis,  he 
should  be  very  slow  to  make  a  diagnosis  of  nontuberculous  hemor- 
rhage, and  should  use  every  possible  means  at  his  disposal  before 
accepting  it. 

Pain. — Pain,  while  not  a  very  valuable  symptom  in  plithisis,  is  often 
a  very  early  one.  De  Eenzi  ('94)  claims  that  it  is  present  in  two  thirds 
of  all  early  cases,  and  Peter  considered  it  a  valuable  early  diagnostic 
sign.  The  writer  does  not  consider  it  a  sign  of  great  value,  nor  has  he 
found  it  present  in  so  large  a  percentage  of  cases,  but  it  is  fairly  fre- 
quent, and  combined  with  other  findings  can  at  times  be  an  aid  in 
diagnosis.  As  a  rule,  the  pain  is  not  very  intense,  but  it  is  fairly  con- 
stant, is  a])t  to  be  increased  by  cougliing,  and  later  in  the  disease  gen- 
erally disap]jears.  It  is  usually  a  dull  aching  or  boring  pain,  most 
common  in  the  supi'aclavicular  fossa  or  in  the  supraspinous  fossa,  in 
which  last  location  it  often  is  manifested  as  a  burning  spot,  which  is 
probably  due  to  an  apical  pleurisy  with  adhesions  forming. 

At  times  quite  a  sharp  neuralgic  ])ain  will  be  felt  in  the  point  of  the 
shoulder,  in  front,  with  each  cough  or  with  much  motion  of  the  arm. 
When  in  the  shoulder  the  pain  is  often  mistaken  for  rheumatism,  and 
patients  have  been  known  to  visit  a  well-known  hydropathic  institution 
to  be  treated  for  some  time  on  a  diagnosis  of  rheumatism,  the  real 
trouble  not  being  discovered  until  the  patient  left  tlie  institution.  This 
early  apical  jjain  can  be  relieved  by  the  application  of  small  fly  blisters. 
It  may  precede  for  months  the  appearance  of  a  demonstrable  lesion. 
The  writer  has  known  one  of  the  best  diagnosticians  of  this  trouble  in 
the  country  to  be  unable,  on  the  most  thorough  examination,  to  find 
any  trouble  at  the  site  of  such  a  pain,  although  considerably  later  a 
lesion  appeared  there.  Therefore,  even  in  the  absence  of  physical  signs, 
such  pain,  if  persistent,  can  be  regarded  as  very  suspicious  and  should 
cause  one  to  follow  the  case  with  care. 

At  this  stage  pain  on  pressure  or  percussion  is  not  common,  but  a 
little  later,  when  the  process  is  more  pronounced,  pain  on  percussion, 
especially  above  the  spine  of  the  scapula,  and  between  it  and  the  ver- 
tebrge,  or  over  the  site  of  congestions  or  cavities,  is  very  common,  and 
over  cavities  will  generally  persist.  An  infiltrated  apex  will  often  pro- 
duce a  general  sense  of  soreness  and  aching  in  the  upper  part  of  one 
side  of  the  chest  which  may  be  \evy  trying.  Again,  very  often  active 
motion  will  produce  severe  lancinating  pains  in  the  apex,  due  to  trac- 
tion on  apical  adhesions,  and  violent  exercise,  such  as  riding  a  hard 
trotting  horse,  may  produce  very  severe  paroxysms  of  such  pain. 


SUBJECTIVE   SYMPTOMS  223 

As  a  rule,  the  pain  in  the  lungs  in  tuherculosis,  even  if  it  persists, 
is  not  constant,  being  present  only  at  intervals,  especially  when  the 
patient  has  overexerted  himself  in  some  way.  A  dull  aching  pain  be- 
tween tlie  shoulder  blades  is  common  and  very  fatiguing,  but  the  writer 
has  never  seen  the  severe  insistent  and  intolerable  pain  in  this  region, 
demanding  morphin  for  its  relief,  referred  to  by  Aufrecht  ('05). 

More  common  in  this  stage  is  a  general  aching  of  a  large  area  of 
the  affected  lung,  with  a  drawn,  tight  feeling.  The  patient  is  aware 
that  he  has  a  lung,  and  feels  that  it  is  bound  down  and  cannot  expand. 
Localized  pleurisies  generally  manifest  themselves  by  sharp,  sticking 
pains,  increased  by  pressure  in  the  intercostal  spaces;  but  it  is  strange 
how  seldom  in  tuberculosis  one  finds  frictions  over  the  site  of  undoubted 
pleuritic  pains,  while  very  often  large  areas  of  plain  pleuritic  friction 
with  no  pain  at  all  are  discovered. 

The  distinction  of  pleuritic  pains  from  intercostal  neuralgia  is  at 
times  difficult,  but  generally  the  latter  can  be  demonstrated  by  follow- 
ing the  intercostal  space  to  the  spine,  finding  tenderness  all  along,  and 
especially  tenderness  over  the  nerve  root.  Pleurisy  of  the  lower  anterior 
chest  will  manifest  itself  at  times  by  referred  pain  in  the  abdomen,  and 
thus  subdiaphragmatic  pain  in  the  tuberculous  should  call  for  careful 
examination  of  the  lower  thorax,  as  Fowler  ('98)  points  out.  Xot 
infrequently  patients  will  complain  of  pain  in  the  heart  region,  which 
is  due  to  pericardial  ])leural  adhesions.  In  the  later  stages  of  tubercu- 
losis pain  is  not  so  common,  except  on  percussion,  and  it  is  apt  to  be 
in  the  lower  portions  of  the  lungs,  owing  to  spread  of  superficial  pleu- 
risy, which  is  accompanied  by  pain  at  the  base  of  the  lungs  and  a  feeling 
of  constriction. 

In  advanced  cases,  with  severe  coughing,  the  abdominal  muscles  and 
the  insertion  of  the  diaphragm  may  become  exceedingly  tender,  so  as  to 
cause  the  patient  a  great  deal  of  suffering.  Very  usually  in  such  cases 
the  sites  of  cavities  are  tender  on  jjressure,  and  quite  frequently,  pre- 
ceding a  hemorrhage,  patients  will  complain  of  a  dull  ache  in  these 
spots. 

In  speaking  of  the  nervous  manifestations  of  tuberculosis,  reference 
has  already  been  made  to  the  gi'eat  frequency  in  neurotic,  and  more 
especially  Jewish,  patients  of  fleeting  thoracic  pains,  of  nervous  origin, 
ap])earing  and  disappearing  irregularly  in  various  parts  of  the  chest, 
but  I  have  never  l)een  able  to  determine  any  connection  between  them 
and  any  pulmonary  change,  or  that  they  have  any  bearing,  favorable  or 
unfavorable,  on  the  course  of  ilie  disease.  The  severest  pain  in  phthisis 
is  that  accompanying  .iiid  rollowiiig  the  occurrence  of  a  juieumothorax. 
This  can  be  so  severe  and  agonizing  as  scarcely  to  yield  to  morphin,  and 
lasts  for  a  number  of  days. 


224  SYMPTOMATOLOGY   OF   PULMONARY  TUBERCULOSIS 


OBJECTIVE    SIGNS 

Inspection. — Form  of  Chest. — Tn  incipient  cases  the  chest  does  not 
usually  show  any  marked  changes  from  the  normal,  and  many,  if  not  a 
majority,  of  such  patients  have  a  good  general  huild  and  a  well-shaped 
chest,  the  paralytic  thorax  once  considered  so  typical  being  found  in 
only  a  very  few  incipient  cases  whose  develoj^ment  it  antedates,  though 
it  is  common  in  the  advanced  stages  of  the  disease.  Aufrecht  ('05), 
however,  notes  that  the  real  paralytic  thorax  differs  from  the  thorax  seen 
in  cases  of  advanced  tiiljerculosis  in  that  in  the  latter  the  chest  falls  in, 
while  in  the  former  it  sinks  down. 

The  frequency  of  well-formed  chests  in  early  cases  will  be  recognized 
when  it  is  recalled  that  Alison  ('61),  after  the  examination  of  6,000  chests 
at  the  Consumption  Hospital  at  Brompton,  found  "  comparatively  few  dis- 
torted chests  among  phthisical  patients — not  more,  in  proportion,  than 
are  found  in  persons  not  suffering  from  phthisis,"  and  that  Brown  and 
Pope  ('04  B)  found  83  per  cent  of  well-formed  chests  in  193  incipient 
cases,  while  Serailler  (Herard,  etc.,  '88,  p.  497)  in  60  cases  of  all  stages 
found  28  normal  chests,  and  concluded  that  "  more  than  one  half  of  all  the 
phthisical  have  a  regularly  formed  chest." 

The  paralytic  thorax,  when  seen,  speaks  for  a  pronounced  hereditary 
taint,  and  in  this  stage  undoubtedly  antedates  tuberculosis  and  is  not 
a  result  of  it.  The  chest  is  long,  narrow,  and  apparently  flat,  the  ster- 
num flat,  the  clavicles  and.scapuhv  prominent,  the  angle  narrow,  the 
ribs  oblique  and  their  interspaces  wide,  the  skin  delicate  and  semi- 
transparent,  the  hair  fine  and  silky  and  often  red  blonde  (Figs.  36 
to  3S). 

Woods  Hutchinson  ('03)  maintains  that  the  shape  of  the  tuberculous 
thorax  is  not  always  really  flat,  but  often  only  apparently  so,  and  as  a 
result  of  his  studies  he  claims  that  instead  of  being  generally  flat,  as  was 
formerly  thought,  it  is  unusually  round,  the  antero-posterior  diameter 
being  about  80  per  cent  of  the  transverse  instead  of  68  per  cent,  which  he 
considers  the  normal  thoracic  index.  This  he  believes  to  be  a  persistence 
of  the  infantile  typo  of  thorax,  and  the  discovery  of  an  index  of  80  or 
moi-e  in  a  person  over  eighteen  years  of  age  he  believes  raises  a  strong 
suspicion  of  tuberculosis. 

Bessensen  ('05)  accepts  these  views  and  considers  that  phthisical  chests 
show  an  arrest  of  the  development  of  the  transverse  diameter  which  should 
follow  puberty.  Brown  and  Pope  ('04  B),  in  a  careful  review  of  the  sub- 
ject, and  as  a  result  of  the  study  of  a  large  series  of  cases  from  vari- 
ous sources  come   to  different  conclusions.     They  found   the  normal   in- 


OBJECTIVE   SIGNS 


225 


dex  to  be  73,  that  in  early  tu- 
berculosis 72,  and  in  advanced 
cases  70,  and  while  they  be- 
lieved that  the  advance  of 
the  disease  tends  to  increase 
the  index,  they  consider  that 
this  needs  confirmation.  They 
found  that  these  cases  tended 
to  show  two  types,  one  with  a 
flat  chest,  with  a  low  index  of 
68  to  70,  and  one,  deep  and 
round,  with  an  index  of  78  to 
80,  but  both  reduced  in  size. 
This   agrees    with    the    conclu- 


FiG.  36. 


Fig.  37. 

there  should  be  8  sq.  cm.  f)f 
thoracic  section  for  each  kilo 
of  body  weight.  Bezangon  also 
('06)  concludes  that  the  trans- 
verse diameter  is  more  devel- 
oped than  the  antero-postcrior, 
which  is  generally  lessened, 
and  considers  that  there  are 
two  types — the  flattened  chest, 
which  he  connects  with  the 
usual  form  of  chronic  tuber- 
culosis, and  the  globular, 
which  he  considers  common- 
est   in    tubercvdosis    with    em- 

])hysema. 

10 


Figs.  36  to  38.  — Rapidly  De- 
structive Process  of  but 
Six  Weeks'  Duration,  but 
Resembling  an  Advanced 
Chronic  Case.  Note  typical 
lateral  view.  Note  change  of 
left  apical  resonant  area.  Ex- 
tensive cavities  in  both  lungs. 

sions  of  Joifres  and  Maurel 
('05),  who  consider  the  index 
variable,  but  the  perimeter  and 
thoracic  section  always  lessened. 
According     to     these     authors 


Fig.  38. 


226  SYMPTOMATOLOGY   OF   PULMONARY  TUBERCULOSIS 

The  writer  has  for  a  number  of  3'ears  taken  cyrtometer  tracings  of 
the  chests  of  all  his  patients  at  the  level  of  the  fourth  costal  cartilage  at 
the  sternum  in  front  and  of  the  eighth  dorsal  spine  behind,  and  while  he 
has  not  estimated  the  index  of  all  of  these  outlines,  he,  like  the  authors 
quoted,  has  not  noted  any  such  preponderance  of  narrow,  deep  chests 
as  Hutchinson  reports,  and,  indeed,  in  the  very  advanced  cases  he  has 
found  a  large  number  of  very  fiat,  broad  chests,  with  an  outline  sug- 
gesting that  of  a  kidney  bean,  which  agrees  with  tracings  given  by 
Kuhn  ('99).  Since,  however,  as  Brown  ('04  A)  has  shown  very  slight 
differences  in  level  make  great  differences  in  the  index,  this  question 
cannot  be  finally  settled  until  all  observers  agree  on  and  use  the  same 
points  in  taking  their  measurements. 

The  writer  is  certain,  as  a  result  of  the  study  of  very  many  tracings, 
that  the  unduly  flat  chest  is  rare  in  early  tuberculosis,  but  common  in 
late  cases,  and  that  as  the  disease  improves,  the  thorax,  with  few 
exceptions,  becomes  deeper  as  well  as  wider,  and  that  if  the  patient 
does  badly  the  opposite  tends  to  occur. 

As  to  the  relation  of  the  perimeter  to  the  height  of  the  patient,  all 
observers  agree  that  it  tends  to  be  less  than  one  half,  and  that  a  thorax 
showing  such  a  decreased  perimeter  measurement  is  suspicious. 

At  times  one  finds  patients  who  present  a  typical  barrel-shaped 
emphysematous  chest,  chiefly  middle-aged  or  old  men,  the  emphysema 
antedating  the  tuberculosis  for  years.  In  these  cases  the  course  is  usu- 
ally favoral)le,  Init  the  diagnosis  is  a])t  to  be  rendered  difficult  by  the 
emphysema  of  the  lung  tissue,  the  shape  of  the  thorax,  and  the  asth- 
matic breath  sounds  so  often  present  in  such  cases  which  mask  the 
signs  of  tuberculosis. 

While  tlie  ])resence  of  tuberculosis  in  the  chest  produces  in  the  be- 
ginning but  slight  changes  in  the  general  form  of  the  thorax,  it  is 
responsible  for  various  small  alterations  which  can  be  found  on  care- 
ful inspection  and  which  are  of  great  value  in  the  diagnosis  of  the 
disease.  The  most  important  of  these  early  changes  are  alterations, 
first  in  tlie  outline  in  the  upper  border  of  the  chest  between  the 
neck  and  tip  of  the  shoulder,  and  then  in  the  supraclavicular  fossa 
and  clavicle.  These  depend  on  a  lessened  functional  activity  of  the 
lungs,  with  the  accompanying  lessened  volume  of  the  organ,  and, 
somewhat  later,  on  retraction  of  the  apex  and  wasting  of  the  shoulder- 
girdle  muscles. 

These  changes  are:  first,  a  slight  shoulder  droop,  the  point  of  the 
shoulder  on  the  affected  side  being  from  half  an  inch  to  an  inch  lower 
than  that  on  the  good  side;  second,  a  slight  flattening  or  a  very  slight 
hollowing  of  the  supraclavicular  fossa;  third,  a  retardation  or  limitation 
of  the  motion  of  the  affected  side;  and  fourth,  a  slight  flattening  of  the 


OBJECTIVE   SIGNS 


227 


muscular  outline  of  the  shoul- 
der, owing  to  a  wasting  of  the 
trapezius. 

The  shoulder  droop  is  found 
very  early,  and  is  present  in 
a  majority  of  cases,  hut  in 
those  who,  like  clerks,  have 
worked  much  at  desks,  it  can 
be  simulated  by  the  lifting  of 
one  shoulder  wliich  this  ])ro- 
duces  and  which  leads  to  the 
belief  that  the  other  shoulder 
is  lowered.     The  acromial  end 


Fig.  40. 

which  in  health  is  usually 
slightly  convex,  is  flattened  or 
even  very  slightly  hollowed, 
and  the  clavicle  is  usually 
slightly  more  prominent  on 
the  affected  side,  and  rarely, 
except  in  those  who  have  been 
used  to  hard  manual  labor, 
is  there  any  prominence  on 
the  good  side  such  as  Brown 
('04  A)  has  noted.  The  (lal- 
tening  of  the  supraclavicular 
fossa  at  this  time  is  duo  solely 


Fig.  39. 

Figs.  39  to  41. — Shows  Chest 
Outlines  and  Limitations  of 
Resonant  Area,  Right  Shoul- 
der Droop.  Prominence  of 
right  clavicle  and  hollowing  be- 
low it. 

of  the  clavicle  is  likewise  low- 
ered, a  point  on  which  Auf- 
recht  ('05)  lays  especial  stress, 
but  which  has  the  same  signifi- 
cance as  the  shoulder  droop, 
and  goes  hand  in  hand  with 
it.     The  supraclavicular  fossa. 


Fig.  41. 


228  SYMPTOMATOLOGY   OF   PULMONARY  TUBERCULOSIS 

to  the  slii'inkafi^e  of  the  lung  wliieh  comes  with  tlie  lessened  function 
produced  ])y  tiie  disease,  the  lung  having  heen  shown  to  change  in  vol- 
ume quite  ra|)idly,  with  increased  or  decreased  functional  activity  (Le 
Grange).  8uch  flattening  in  very  early  cases  is  not  due  to  fibrosis  or 
to  the  shrinkage  of  pleural  adhesions  which  in  later  cases  if  responsible 
for  it.  This  early  flattening  or  hollowing  the  writer  has  again  and 
again  found  to  disappear  if  the  process  is  arrested  and  cured,  while 
in  advanced  cases  the  greater  hollowings  wliich  occur  can  be  compen- 
sated for  or  replaced  by  an  actual  convexity,  if  much  emphysema 
develops.  The  infraclavicular  fossa  does  not  usually  show  much  hol- 
lowing in  the  early  cases,  though  sometimes  the  hollowing  will  be  here 
and  not  above  the  clavicle. 

Motility  of  Chest. — Retardation  or  limitation  of  motion  are  very 
early  signs,  and  cond)ined  with  shoulder  droop  and  supraclavicular  flat- 
tening justify  a  strong  suspicion  of  apical  involvement.  In  retardation 
the  lung  starts  to  expand  and  the  shoulder  to  rise  more  slowly  than 
the  other,  it  seems  to  move  in  jerks,  and  does  not  reach  its  full  expan- 
sion and  elevation  as  soon  as  the  other.  In  limitation  of  motion,  on 
the  contrary,  while  not  starting  later,  it  never  expands  fully,  and  such 
limitation  can  vary  from  a  very  slight  degree  in  early  cases  to  absolute 
immol)ility  in  cases  of  extensive  trouble.  Brown  ('04  A)  finds  limitation 
of  motion  at  the  apex  often  accompanied  by  exaggerated  motion  at  the 
base. 

In  looking  for  changes  of  motion,  one  should  distinguish  between 
the  vertical  raising  of  the  chest,  which  is  best  seen  by  watching  the 
shoulders  and  clavicles  or  scapulte  from  in  front  or  behind  the  patient, 
and  the  expansion  of  the  chest,  which  takes  place  from  behind  forward, 
and  is  best  observed  from  behind  and  above  the  patient,  with  head  bent 
forward,  looking  down  the  front  of  the  two  sides  of  the  chest.  Some 
limitation  or  retardati(m  of  motion  will  be  noticed  in  a  large  majority 
of  all  early  cases,  and  when  it  is  not  made  out  by  inspection  it  can  often 
be  found  by  palpation.  However,  in  cases  with  a  healed  lesion  at  one 
apex  and  a  new  ])rocess  developing  at  the  other,  any  of  these  signs  may 
be  more  pronounced  on  the  side  of  the  old  lesion  and  thus  deceive. 
Occasionally  there  is  retardation  on  the  apparently  unaffected  side,  but 
where  this  condition  exists,  one  should  examine  very  carefully  for 
signs  of  an  old  healed  lesion  and  for  a  history  of  past  trouble  on 
that  side. 

As  the  process  advances,  these  signs  all  become  more  pronounced, 
the  infraclavicular  and  supraclavicular  fossa  show  marked  hollowing, 
the  clavicle  stands  out  like  an  arch,  the  shoulder  droop  becomes  very 
pronounced,  the  shoulder  muscles  waste,  and  respiratory  motion  becomes 
more  and  more  limited.     The  angle  of  Louis,  between  the  manubrium 


OBJECTIVE   SIGNS 


229 


and  the  gladiolus,  tends  to  obliterate,  decreasing  from  a  normal  of  IG 
degrees  to  anything  between  8  and  0  degrees.  As  Alison  ('Gl)  says: 
"  The  sternum,  instead  of  presenting  a  projecting  line  as  it  descends, 
tends  to  become  perpendicular, 
or  it  may  even  incline  inward 
as  it  passes  down."  D.  Eoths- 
child  ("07)  has  pointed  out  that 
this  flattening  can  at  times 
be  hidden  by  the  formation 
of  an  exostosis  at  this  point 
running  transversely  across  the 
bone  and  simulating  a  promi- 
nent anffle. 


At  times  enlarged  bronchial 
glands  can  cause  a  buckling 
forward  of  the  upper  sternum 
at  the  junction  of  the  body  and 
the  manubrium,  and  in  one 
case,  presumably  cancer  of  these 
glands,  the  writer  has  seen  this 
occur  very  rapidly  and  jjroduce 
great  deformity. 


Fig.  42. 


With  a  sinking  of  the  ster- 
num, the  angle  which  tlie  ribs 
make  with  the  vertical  line 
becomes  more  acute.  The  af- 
fected side  begins  to  flatten,  at 
first  in  its  upper  third  and 
then  more  generally,  and  loses 
its  normal  convexity,  and  this 
may  increase  until  all  of  one 
side  of  the  chest  is  flat  and 
smaller  than  tlie  other,  with 
inward  dislocation  of  the  nip- 
ple in  front  and  of  the  angle 
of  the  scapula  behind. 

Distortion  of  the  thorax,  wliicli  is  unusual  in  incipiciit  cases,  is  quite 
commonly  met  with  in  the  chronic  forms  of  advanced  tuberculosis,  but 
acute  cases  run  their  whole  course  without  any  change!  occurring  in  the 
shape  of  the  chest,  and  in  these  cases  one  is  frc(]uently  struck  with  the 
finely  shaped  chests  one  sees  in  people  with  severe  trouble  and  hopeless 
outlook. 


Fig.  43. 

Figs.  42  and  43. — Prominent  Angle  of 
Louis  and  Funnel  Below  It. 


230    SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

The  distortions  of  advanced  cases  are  of  two  sorts,  local  and  general. 
Local  distortions  are  either  manifestations  of  alterations  in  the  under- 
lying lung,  such  as  fd^rosis,  pleural  adhesions,  or  cavitation,  or  of  scoli- 
osis or  rachitis.  In  marked  fihrosis  the  shrinkage  can  cause  numerous 
variations  in  the  shape  of  the  chest,  more  commonly  manifested  as  bulg- 
ings  of  the  ribs  at  the  costochondral  junctions,  especially  of  the  second 
and  third  ribs  on  the  right.  An  old  pleurisy  may  cause  severe  contrac- 
tions which  may  draw  the  whole  trunk  over  to  the  affected  side,  shorten- 
ing that  side  of  the  chest.  Over  old  superficial  cavities  in  the  upper 
third  of  the  chest,  saucerlike  depressions  are  often  seen,  and  since 
cavities  are  commonest  in  the  upjier  third  of  the  left  lung,  these  hollows 
are  usually  seen  to  the  left  of  the  u])})er  portion  of  the  sternum. 

Scoliosis,  if  looked  for  carefully,  will  be  found  present  in  slight 
degree  in  a  considerable  number  of  early  cases  (Brown  found  it  in  23 
of  10,3  cases).  It  causes,  if  marked,  a  bulging  of  the  posterolateral  as- 
pect of  the  ribs  on  the  side  of  the  convexity.  This  bulging  is  especially 
well  demonstrated  by  the  cyrtometer,  and  if  not  recognized  may  confuse 
the  percussion  findings,  such  bulgings  producing  relative  dullness.  Such 
scolioses  are  generally  single  and  usually  in  the  lower  dorsal  regions, 
but  they  are  at  times  double  in  the  dorsal  and  lumbar  regions.  If  the 
patient  does  well  they  will  disappear  as  health  returns.  Kyphosis  is 
seen  but  rarely. 

Eickets  is  responsible  for  alterations  in  the  shape  of  the  lower  por- 
tion of  the  thorax,  chiefly  along  the  insertion  of  the  diaphragm,  where 
its  results  are  seen  as  Harrison's  groove,  a  transvei'se  hollow  across  the 
chest  at  this  level.  The  intercostal  angle,  which  shoidd  be  nearly  a  right 
angle,  is  often  more  acute  than  normal,  and  in  those  with  a  paralytic 
thorax  and  in  old  cases  of  tuberculosis,  may  become  so  narrow  that  the 
free  borders  of  the  ribs  are  parallel  with  each  other  and  almost  touching 
for  two  or  three  inches  downward  from  the  ensiform  cartilage. 

The  funnel  chest  ("  Trichterbrust "  or  "  Schusterbrust ")  is  seen 
quite  commonly  in  moderately  advanced  and  advanced  cases,  but  pro- 
nounced degrees  are  rare.  In  this  deformity  the  sternum  and  neigh- 
boring costal  cartilages  are  drawn  inward  to  form  a  somewhat  funnel- 
shaped  depression  in  the  center  of  the  chest,  this  depression  being 
commonest  between  the  fourth  rib  and  the  ensiform,  though  it  may  oc- 
cur at  any  portion  of  the  sternum.  In  extreme  cases  the  costal  angle  is 
drawn  inward  along  with  the  ensiform.  These  funnel-shaped  depres- 
sions are  probably  the  result  of  obstruction  to  the  entrance  of  air  into 
the  larynx  in  childhood,  while  the  bones  are  soft  by  reason  of  rickets, 
but  may  be  congenital.  The  writer  has  seen  an  identical  deformity  of 
this  sort  in  a  brother  and  sister,  the  thorax  of  one  being  an  exact  repro- 
duction of  that  of  the  other  (Fig.  42). 


OBJECTIVE    SIGNS  231 

The  scapiilce  show  no  change  of  position  until  the  process  is  well 
pronounced,  except  the  dislocation  inward  which,  as  already  noted, 
occurs  when  the  side  is  shrunken,  hut  after  this  time  there  is  apt  to 
develop  a  slight  degree  of  prominence  of  the  angle  on  the  affected  side, 
and  as  the  disease  advances  this  hecomes  more  and  more  marked,  the 
angle  rotating  outward  and  getting  more  and  more  prominent  until  it 
looks  like  a  wing,  hence  the  term  "  alar."  Except  for  those  slight 
changes  in  the  shoulder-girdle  muscles  spoken  of  earlier,  there  is  no 
alteration  in  the  muscles  until  the  process  is  far  enough  advanced  for 
atrophy  to  occur,  though  in  patients  with  a  paralytic  thorax  the  mus- 
cles are  apt  to  be  relaxed  and  tlal)by.  In  cases  with  much  activity  there 
may  be  a  local  wasting  of  the  muscles  over  the  focus  of  the  trouble 
or  over  a  cavity,  and  Desplatz  (De  Renzi,  "94)  even  considers  most  of 
the  deformities  of  the  chest  due  to  the  wasting  of  the  muscles. 

The  skin  of  the  chest,  in  rapidly  advancing  cases  or  where  there  is 
much  wasting,  shares  in  the  general  malnutrition  and  is  pale  and 
atrophic;  in  the  incipient  cases  it  may  not  offer  any  unusual  aspect. 
The  dilated  superficial  veins  seen  on  some  chests,  S.  West  ('02)  con- 
siders evidence  of  pleural  adhesions,  a  view  shared  by  K.  Francke  ('07), 
who  attributes  to  the  fine  vascular  areas  over  the  apices  diagnostic  sig- 
nificance in  early  tuberculosis.  In  women  the  breast  on  the  side  of 
the  trouble  is  apt  to  be  smaller  than  that  of  the  other,  but  the  difference 
in  the  size  of  the  areola,  noted  by  some  Italian  observers,  the  writer  has 
not  seen.  The  apex  beat,  if  fibrosis  is  marked,  is  dislocated,  and  when 
the  upper  portion  of  the  left  lung  is  retracted  from  this  cause  pulsation 
can  be  seen  over  the  pulmonary  valve. 

The  fades  is  unaltered  in  early  cases,  except  that  the  cheek  of  the 
affected  side  flushes  on  exertion  or  excitement,  which  foreruns  the 
development  of  a  more  pronounced  hectic  flush.  The  pupil  of  one 
side  or  the  other  is  frequently  dilated,  but  not  always  on  the  side 
of  the  lesion,  as  has  been  asserted.  In  cases  of  young  people  with 
severe  trouble  of  an  active  nature,  the  writer  has  frequently  noted  a 
dilatation  of  both  pupils,  and  has  found  it  to  be  of  a  bad  prognostic 
significance. 

The  inspection  of  the  mouths  of  patients  should  not  be  omitted,  as 
good  teeth  are  necessary  to  good  digestion,  and  the  teeth  of  the  tuber- 
culous are  often  in  very  bad  shape,  and  are  a  handicap  to  progress. 
Thompson's  red  line  along  the  gums  is  not  present  in  many  early  cases, 
though  often  in  advanced  ones.  The  tongue,  as  is  natural  in  a  disease 
where  dyspepsia  is  so  often  present,  often  shows  some  slight  degree  of 
coating  and  it  is  pale  and  flabby,  while  in  old  eases  with  intestinal 
lesions  or  severe  gastritis  it  is  fiery  red  and  shiny.  Ulcers  of  the  tongue 
are  rare. 


232     SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

Follicular  pharyngitis,  or  pharyngitis  sicca,  is  quite  common,  the  lat- 
ter chiefly  in  old  cases. 

Palpation. — Although  not  of  tlu'  greatest  value,  palpation  at  times 
gives  useful  information,  so  that  it  should  not  he  omitted.  It  gives 
evidence  of  respiratory  expansion,  of  alterations  in  the  conducting 
jiower  of  the  lung  tissue  hy  vocal  fremitus,  demonstrates  frictions,  re- 
veals painful  pressure  points,  the  location  of  the  heart  beat,  and  enlarged 
cervical  or  abdominal  glands. 

As  a  method  of  determining  respiratory  motion,  it  is  frequently 
superior  to  inspection.  The  finger  tips,  laid  over  the  apices  or  sides 
of  the  lung,  will  note  very  slight  differences  in  expansion,  and  inspection 
findings,  if  uncertain,  should  always  be  tested  by  this  method.  The 
determination  of  vocal  fremitus  has  only  a  restricted  value;  useless  in 
incipiency  and  too  varied  to  be  interpreted  in  the  third  stage,  it  is  only 
in  the  end  of  the  first  and  in  the  second  stage  that  it  is  of  iise.  The 
vibrations  of  the  u])pcr  riglit  lung  being  normally  much  stronger  than 
that  of  the  left,  an  increase  at  the  right  apex  must  be  very  pronounced 
to  make  certain  that  it  is  pathologic,  although  such  an  increase  at  the 
left  apex  is  suggestive.  Slight  changes  at  the  left  can  ])e  assumed 
when  one  finds  the  fremitus  over  the  left  apex  equal  to  that  over  the 
right.  As  Lindsay  (04)  says:  "If  the  fremitus  be  equal  on  the  two 
sides  and  marked,  suspect  a  lesion  of  the  left  apex.  If  it  be  equal  on 
the  two  sides  and  ill  marked,  suspect  the  right  side."' 

Diminished  fremitus  should  suggest  emphysema,  thickened  pleura, 
occlusion  of  a  bronchus,  or  fluid,  the  first  and  second  being  by  far  the 
most  common  causes.     However,  lessened  fremitus  is  not  common. 

Monneret  (Grancher,  '90)  insists  that  the  variations  in  the  fremitus 
must  not  only  be  taken  between  the  two  sides,  but  relatively  on  each 
side  alone.  The  location  of  the  maximum  fremitus  in  the  lung  depends 
on  the  pitch  of  the  voice,  it  being  higher  up  in  proportion  as  the  pitch 
is  higher,  so  that  in  women  and  children  it  is  strongest  in  the  upper 
part  and  nearly  absent  below,  while  in  men  with  strong  voices  it  is 
strongest  at  the  base.  Thus,  in  a  doubtful  case  in  a  man  with  a  low- 
pitched,  resonant  voice,  where  the  comparative  fremitus  between  sides 
is  normal,  the  discovery  that  the  fremitus  at  the  apex  is  equal  to  that 
at  the  base  would  greatly  strengthen  suspicions  of  apical  consolidation. 

In  advanced  cases  with  multiple  lesions  palpation  is  valueless.  It 
should  not  be  forgotten  that  a  narrow  band  of  adhesions  can  conduct 
fremitus  strongly  under  certain  conditions,  so  that  at  times  it  can  be 
carried  to  distant  parts,  as,  for  instance,  in  pneumothorax  or  pleurisy. 
Palpation  for  frictions  or  for  ronchi  is  of  no  importance,  and  may  be 
neglected.  Pain  on  palpation  is  present  in  a  fair  number  of  the  early 
cases  over  the  apex  in  front  or  behind.    It  is  commonest  behind,  between 


OBJECTIVE  SIGNS  •  233 

tlie  spine  of  tlio  scajnila  and  tlie  spinal  column.  Eibard  (quoted  by 
Cornet,  "U7,  p.  G57)  ascribes  Ibis  to  enbiri^'-ed  bronchial  «);lands.  Head's 
painful  points,  while  they  may  at  times  be  discovered,  have  given  the 
writer  no  aid  in  the  study  of  his  cases,  and,  according  to  Fowler  and 
Godlee  (*98),  to  connect  them  with  lesions  of  special  portions  of  the 
lungs  "is  a  work  of  some  difficulty/' 

It  is  surprising  how  seldom  enlarged  cervical  glands  are  found. 
When  present  they  are  commonest  on  the  side  of  the  lesion  in  the  lung. 

Tlie  necessity  of  palpating  for  the  apex  beat  need  scarcely  be  noted. 
When  determined,  the  point  should  be  marked  with  a  blue  skin  pencil, 
so  as  to  be  used  later  in  mensuration.  Displacement  of  the  apex  beat 
to  any  marked  degree  suggests  fibrosis,  except  where  it  is  due  to  pleuritic 
effusion  or  pneumothorax.  The  heart  beat  can  be  felt  very  distinctly 
as  well  as  seen  over  the  pulmonary  valve  in  filiroid  cases,  owing  to  re- 
traction of  the  lung,  though  Cornet  ascribes  this  to  infiltration  of  the 
anterior  l)order  of  tlie  upjier  lol)e. 

Mensuration. — Tlu'  full  circumference  of  the  chest  should  be  at  least 
one  half  the  height  of  the  patient,  chests  under  this  proportion  suggesting 
a  weak  constitution.  This  circumference  should  be  measured  at  the 
level  of  the  fourth  rib  at  the  sternum  in  front  and  the  eighth  dorsal 
spine  behind,  the  chest  being  at  rest,  but  Loomis  ('98)  advises  the 
average  of  extreme  inspiration  and  expiration.  Brown  ('04  A)  found 
the  circumference  less  than  half  the  height  in  45  per  cent  of  80 
male  cases  and  in  75  per  cent  of  1)5  female  cases,  which  led  him  to 
suggest  that  the  standard  was  probably  formed  from  the  measurement 
of  males. 

The  expansion  of  the  chest,  according  to  Fetzer  (Yierordt,  \Sfl), 
is  from  l.G  inches  to  4.8  inches,  which  does  not  ditfer  much  from  the 
figures  of  Draper,  who  gives  it  as  fiom  2  to  5  inches,  and  this  is  much 
nearer  the  truth  than  the  considerably  smaller  figures  given  by  other 
authors.  With  such  wide  normal  limits  of  variation,  it  is  evident  that 
in  early  cases  its  determination  is  of  little  value,  and  the  writer  has 
frequently  seen  such  patients  with  an  expansion  of  4  inches  or  over, 
but  the  loss  of  expansion  during  the  advance  of  the  disease  and  its 
increase  during  its  improvement  is  so  usual  that  if  taken  at  successive 
examinations  its  determination  can  throw  some  light  on  the  progress 
of  the  case.  While  a  knowledge  of  the  total  circumference  of  the  chest, 
except  as  suggesting  a  weak  resisting  power,  is  of  little  value,  a  knowl- 
edge of  the  two  semicircumferences  is  of  considerable  value  and  should 
always  be  sought.  Despite  the  contrary  view  of  Waldenburg  (*80),  a 
marked  lessening  of  the  right  side  of  the  chest  in  right-handed  people, 
or  of  I  be  left  side  in  left-handed  ones,  is  good  evidence  of  the  existence 
of  a  lesi(m  on  that  side,  while  a  ])rogressive  shrinkage  of  the  affected 
17 


234 


SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 


side  very  imiforml}'  goes  with  an  advancing  process  and  a  reexpansion 
with  an  improving  one. 

Asymmetry  of  the  chest  can  be  demonstrated  by  the  use  of  the  tape 
between  symmetrical  points,  but  the  trained  eye  is  more  vakiable  than  the 
tape  in  determining   asymmetry.      The  calipers   are   useful   in   giving  the 


Fig.  44. — Cyrtometer  Tracing  of  In-      Fig.  45.^ — Case  in  I.  Stage  (R).     Re- 


cipient Case  (I).  Note  shrinkage 
of  R.  side.  Continuous  hne  Dec, 
broken  line  April,  190L  Patient 
right  handed.  (Disease  arrested.) 
Index  65. 


expansion  After  Five  Months 
(Broken  Line).  Disease  arrested 
for  some  years.     Index  63. 


depth  imd  breadth  of  the  chest  and  the  depth  of  corresponding  parts  of 
the  thorax,  especially  in  ils  upper  portion,  which  can  otherwise  only  be 
estimated  by  inspection ;  thus  the  depth  of  the  apex  can  be  measured  from 


Fig.  46. — Active  Recent  Disease  on 
Left  Side,  Arrest,  and  Final  Cure. 
Index  76. 


Fig.  47.^ — Marked  Shrinkage  in  In- 
cipient Left-sided  Case  (I).  Re- 
expansion  very  rapid.  Two  months 
between  two  tracings.     Index  61. 


just  below  the  center  of  the  clavicle  to  the  spine  of  the  scapulae,  or  one 
of  the  dorsal  spines,  as  advised  by  Walsh  ('43). 

The  distance  of  the  heart  apex  from  the  center  of  the  sternum  should 
always  be  measured  as  it  gives  evidence  of  alterations  in  size  or  of  dislo- 
cations. Cunningham  ('03)  gives  the  normal  distance  of  the  apex  from 
the  midline  as  3^  inches.    In  his  tuberculous  patients,  the  writer  has  found 


OBJECTIVE   SIGNS 


235 


it  to  be  rather  less  than  the  normal,  as  an  average,  varying  between  2^-  and 
3^  inches  in  men,  and  from  2  to  3  inches  in  Vv'oraen. 

The  lead  tape  cyrtometer  gives  the  thoracic  perimeter  at  any  given 
level,  and  makes  visible  slight  alterations  of  size  of  one  side  of  the  chest, 
which  could  not  otherwise  be  recognized,  and  more  especially  gives  most 
graphic  ocular  evidence  of  changes  in  shape  during  the  course  of  the 
disease.  It  is  of  great  diagnostic  and  prognostic  value  and  it  is  regret- 
table that  it  is  not  more  generallj-  used.  The  writer  has  used  it  on  all  cases 
for  a  number  of  years  and  through  it  has  been  able  to  demonstrate  a 
slight  shrinkage  of  the  affected  side  in  most  cases  early  in  the  trouble.  A 
slight  shrinkage  of  the  left  side,  except  in  left-handed  people,  is,  of  course, 
of  no  value,  but  such  a  decrease  on  the  right  side  is  of  value  as  suggesting 
trouble  in  the  contracted  lung.  Used  in  successive  examinations,  there 
is  no  method  which  will  give  such  beautiful  demonstrations  of  that 
shrinkage  or  reexpansion  of  the  thorax  which  so  uniformly  follows  ad- 
vancing trouble  or  improvement. 


Fig.  48. — Fibroid  Disease,  Continu- 
ally I.MPROVING.  Showing;  shrinkage 
of  perimeter.  In  this  case  indicating 
improvement.  Tracings  ten  months 
apart.     Index  69. 


Fig.  49. — Stage  III.     Patient  Failing. 
Decrease  in  perimeter.     Index  71. 


It  is  interesting  here  to  note  that,  as  a  rule,  the  increase  of  perimeter 
takes  place  first  on  the  unaffected  side,  which  is  doubtless  due  to  a  com- 
pensatory increase  of  the  good  lung,  and  that  the  increase  of  the  affected 
side  generally  follows  this  increase  on  the  good  side.  The  increase  can 
be  in  breadth  or  in  depth  or  both,  though  more  commonly  in  breadth  than 
in  depth,  but  since  the  former  is  somewhat  affected  by  increase  of  muscle 
and  fat,  it  is  not,  if  moderate,  as  reliable  as  an  increase  in  depth  which, 
being  between  bony  points,  the  sternum  in  front  and  the  spine  of  the 
vertebra  behind,  is  positive. 


The  use  of  tlie  spirometer  is  at  present  largely  neglected.  While 
not  of  as  great  diagnostic  value  as  Hutchinson,  its  chief  advocate,  be- 
lieved, it  is  useful,  especially  in  watching  the  course  of  a  case,  although 


236 


SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 


the  patient  must  be  taught  to  use  it  properly,  and  it  should  not  be 
used  in  any  case  where  there  is  a  tendency  to  hemorrhage.  Even  at  a 
first  examination  a  high  reading  is  not  positive  evidence  of  a  normal 
lung,  since  one  at  times  sees  patients  with  considerable  trouble  who 
can  give  a  high  reading.  An  unduly  low  reading  in  a  patient  who  has 
been  taught  to  use  the  instrument  properly,  always  speaks  for  a  limi- 
tation of  available  lung  and  suggests  tuberculosis,  while  a  high  reading, 
persisting  at  subsequent  examinations  and  coml)ined  with  other  good 
findings,  increases  the  assurance  with  which  one  can  make  a  good  prog- 
nosis. Steady  increase  of  reading  at  each  examination  is  a  uniformly 
good  sign,  and  a  steady  decrease  a  bad  one,  slight  fluctuations  being 
of  no  value. 

Tlie  value  of  this  instrument  is  well  expressed  by  Waldenl)urg  ('80). 
He  says :  "  The  spirometer  is  for  general  diagnosis  of  moderate  value,  but 
is  an  invaluable  means  for  founding  an  individual  diagnosis,  either  as  to 


Fig.  f>(). —  Round  Type  of  Chest. 
Incipient  disease  on  right  side  (I). 
Index  80. 


Fig.    51. — "Pigeon    Chest",    Case    in 
Stage  III.     Index  68. 


the  degree  of  tlie  involvement  or  to  found  a  prognosis  for  observing  the 
course  of  the  disease,  and  finally  for  noting  the  effectiveness  or  useless- 
ness  of  every  given  treatment." 

The  scales  need  scarcely  be  mentioned,  as  they  have  been  treated 
of  under  the  subject  of  emaciation.  Diagnostically  as  well  as  prog- 
nostically  they  are  of  great  use  and  should  be  placed  in  every  examining 
room. 

Corpulence  is  the  relation  of  weight  to  height;  according  to  Loomis 
('98),  the  former  in  pounds,  divided  by  the  latter  in  feet,  should  be 
26  in  normal  men  and  23  in  women,  or,  according  to  Papillon  ('97), 
the  weight  in  hectogrammes  and  tlie  height  in  centimeters  should  be 
3  in  women.  It  ought  to  he  of  value  in  determining  the  resisting  power 
of  patients. 


OBJECTIVE   SIGNS 


237 


Fig.  52. — Fl.a.t  Type  of  Che.st.     Ex- 
pansion in  one  year,  coincident  with 
■    marked   improvement.      Stage   III. 
Patient  for  seven  years  with  Hmited 
working  capacity.     Index  59. 


Percussion. — Although  the  cUiini  of  Aufrecht  ('05)  that  percussion 
"offers  positive  findings  much  sooner  .  .  .  than  auscultation,"  is  per- 
hajis  not  conceded  by  the  majority 
of  observers,  it  must  be  admitted 
that  if  properly  performed,  espe- 
cially over  the  apices,  it  is  of  great 
value  as  a  means  of  early  diag- 
nosis. It  is  to  be  regretted  that  its 
technie  is  so  frequently  imperfectly 
mastered,  as  in  percussion,  more 
than  in  any  other  diagnostic  pro- 
cedure, a  good  result  depends  on 
a  perfect  technie,  and  careful  and 
delicate  percussion  will  yield  re- 
sults which  cannot  be  hoped  for  if 
it  is  heavy  and  improperly  directed. 

When  it  is  recalled  how  slight 
are  the  lesions  in  early  tubercu- 
losis, a  few  small,  scattered  or  con- 
glomerate tubercles  in  an  apex,  with 
some  consequent  relaxation  of  the 
parenchyma,  it  is  evident  that  only 
in  an  apex  could  one  ordinarily 
expect  to  determine  early  changes 
by  percussion  at  all,  and  that  even 
then  one  cannot  expect  to  find 
early  in  the  disease  any  marked 
percussion  changes,  such  as  pro- 
nounced dullness  or  flatness.  On 
the  contrary,  there  is  usually  only 
a  slight  "  shortness  "  of  note,  the 
duration  of  the  note  being  less 
than  on  the  good  side  and  slightly 
elevated  in  pitch,  or  at  most  an 
impaired  resonance  or  very  slight 
dullness,  often  accom])anied  by  a 
slight  tympanitic  overnote,  due  to 
relaxation  of  the  surrounding  lung 
tissue  (Sahli,  '02).  Instead  of  this, 
slight  tympany  or  hyperresonance 
will    at   times    be    found,    as    first 

noted  by  Andral,  but  the  commonest  early  percussion  change  is  a  short, 
high-pitched  note  or  a  slight  impairment  of  resonance,  both  of  which 


Fig.  53. — Bulging  B.\ck"v\^\rd  on  Ac- 
count OF  Scoliosis.  Correction  of 
scoliosis.     Index  54. 


Fig.  54. — Marked  Shrinkage  of  Left 
Side,  Due  to  Post-Pneumonic 
Emphyse.ma.  Restoration  of  normal 
l)erimeter  in  three  months  Ijy  exer- 
cises.    Index  6(3. 


238     SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

are  more  common  and  more  certainly  determinable  than  tympany  or 
hyperresonance.  Aufrecht  ('05)  considers  an  even  earlier  sign  to  be 
the  difference  between  the  percussion  note  on  inspiration  and  expira- 
tion. Da  Costa  ('75)  pointed  out  that  in  the  normal  lung  there  was 
a  difference  in  the  note  on  percussion  in  inspiration  from  that  in  ex- 
piration, the  former  being  duller,  the  latter  clearer.  Aufrecht  considers 
that  in  the  very  early  lesions  in  an  apex  this  is  reversed,  inspiration 
being  clearer  and  expiration  duller. 

In  view  of  this  respiratory  variation,  it  is  wdse  in  doubtful  incipient 
cases  that  the  percussion  blow  should  be  delivered  over  each  apex  during 
the  same  phase  of  respiration,  and  in  percussing  one  spot  to  compare 
the  note  during  inspiration  with  that  during  expiration.  The  slight 
retraction  of  tbe  inner  border  of  the  apex,  with  a  lowering  of  its  height, 
first  pointed  out  by  Ziemssen  and  later  more  fully  studied  by  Kroenig 
and  Oestreich,  is  a  valuable  early  sign  of  a  lesion  in  the  apex,  and  careful 
percussion  will  demonstrate  a  slight  degree  of  such  retraction  in  many 
early  cases.  As  stated  elsewhere  (Minor,  '06),  the  slight  retraction 
found  at  this  stage  is  due  not  to  fibrosis,  which  is  not  yet  present,  but 
to  lessened  functional  activity,  and,  if  the  case  is  soon  cured,  it  can 
disappear. 

It  need  hardly  be  emphasized  again  that  these  slight  incipient 
changes  demand  for  their  detection  the  most  delicate,  light,  resilient 
percussion  possible,  using  one  finger  only,  and  using  the  little  finger 
as  a  pleximeter.  When  there  are  beginning  lesions  in  both  apices,  it 
will  at  times  be  impossible  to  determine  any  change,  and  other  methods 
will  have  to  be  relied  on.  The  slight  decrease  of  resonance,  normal  at 
the  right  apex,  which  was  noted  by  Flint  long  ago  ('75),  renders  slight 
impairment  at  the  left  apex  of  more  value  than  at  the  right,  but  slight 
alterations  at  the  right  are  too  often  ascribed  to  this  normal  difference. 
Where  hyperresonance  is  present  over  an  apex,  one  may  be  deceived  into 
regarding  the  other  apex  as  being  impaired,  and  this  accounts  for  the 
fact,  noted  both  by  Turban  and  Sokolowski,  that  different  competent 
examiners,  examining  the  same  case  in  the  same  day,  may  locate  the 
lesion  in  different  apices. 

Again,  impaired  resonance  over  the  anterior  aspect  of  an  apex  may 
be  accompanied  by  hyperresonance  on  the  posterior  aspect  (Fox,  '91) 
from  relaxation  of  adjacent  lung,  hence  if  hyperresonance  is  noted, 
the  other  aspect  of  the  lung  tissue  should  be  carefully  searched  for 
dullness.  At  times  the  remains  of  an  old  pleurisy  or  a  healed  focus 
at  one  apex  may  produce  slight  dullness  there  and  obscure  the  slight 
signs  at  the  other  side  where  a  new  process  is  beginning,  but,  while 
such  cases  may  be  puzzling,  a  careful  study  of  the  results  of  the  other 
steps  of  the  examination  will  suffice  to  clear  up  the  trouble. 


OBJECTIVE   SIGNS  239 

Distinct  dullness  cannot  be  regarded  as  an  early  sign,  but  speaks  for 
more  pronounced  trouble  and  the  coalescence  of  the  scattered  tubercles 
into  a  solid  mass  of  some  extent  with  little  air-containing  tissue  between. 
Piorry  taught  that  even  superficial  lesions  to  produce  discernible  dull- 
ness must  be  from  4  to  6  cm.  in  width  and  5  cm.  in  thickness.  Alison 
('Gl)  noted  that  a  superficially  located  spot,  one  half  a  square  inch 
in  size  and  one  half  an  inch  deep,  located  in  the  apex,  could  produce 
unquestionable  dullness.  Oestreich  ('98),  as  a  result  of  autopsies,  be- 
lieves that  a  consolidated  area  the  size  of  a  cherry  can  produce  dullness 
with  tympanitic  overnote;  and  Flint  ('75)  reported  an  interesting  case 
where  a  mass  the  size  of  a  hazelnut  was  discovered. 

The  note  over  the  apex  is  not  uniform,  the  outer  portion  being 
slightly  impaired  by  the  underlying  muscles,  the  inner  slightly  tym- 
panitic from  the  neighljorhood  of  the  trachea,  while  the  central  portion 
alone  gives  a  clear  sound,  and  in  early  cases  this  must  be  kept  in  mind 
and  each  of  these  portions  of  the  apex  studied  separately. 

Observers  differ  as  to  the  commonest  seat  of  the  dullness  produced 
by  apical  lesions.  C.  J.  B.  Williams  ('87)  and  Babcock  ('07)  consider 
it  commonest  in  the  suprascapular  fossa,  but  while,  as  Fowler  points 
out  ('98),- lesions  commonly  tend  to  spread  backward,  the  structure  of 
the  overlying  soft  parts  renders  small  foci  less  accessible  to  percussion 
here  than  in  front,  and  dullness  is  most  generally  first  found  in  the 
inner  part  of  the  supraclavicular  fossa  and  in  the  inner  third  of  the 
infraclavicular  region.  This  agrees  with  the  fluoroscopic  findings  in 
early  cases,  which  show  that  a  shadow  in  the  sternoclavicular  angle  or 
above  the  clavicle  is  very  much  commoner  than  a  shadow  behind.  W. 
Walsh  ('71)  and  Alison  ('61)  also  consider  that  this  region  is  usually 
the  first  site  of  dullness.  With  bilateral  apical  lesions  crossed  dullness 
is  often  found,  the  apex  on  one  side  being  dull  in  front,  that  on  the 
other  side  behind. 

At  times  the  first  lesion  will  develop  directly  under  the  clavicle, 
and  the  first  spot  of  dullness  will  be  found  by  percussion  on  this  bone 
and  not  above  or  *below  it,  a  point  noted  first  by  Laennec  ('19)  and 
also  by  Stokes  ("82),  but  we  must  be  sure  that  an  unduly  arched  clavicle 
or  the  thickening  from  an  old  fracture  is  not  responsible  for  the  dull- 
ness. The  writer  has  never  felt  safe  in  laying  much  weight  on  dullness 
limited  to  this  bone. 

The  condition  of  the  soft  parts  and  of  the  bony  thorax  can  have  a 
marked  modifying  effect  on  percussion,  especially  in  the  early  stages. 
The  strong  muscles  of  a  laborer  or  a  thick  layer  of  fat  may  render  per- 
cussion useless,  and  even  the  difference  between  a  normal,  well-nourished, 
ejastic  skin  and  a  thin,  loose,  and  relaxed  one  can  cause  a  difference 
in  note. 


240  SY.MPTOMATOLOGY   OF    PULMONARY   TUBERCULOSIS 

Local  prominences  of  individual  ribs,  or  of  many  riljs,  as  a  result 
of  scoliosis,  can  simulate  dullness,  and  the  unyielding  ossified  thorax 
of  an  old  j^erson  gives  a  rather  dull  note,  whereas  the  elastic  chest  of 
a  young  person  gives  a  sonorous,  h3q)erresonant  one.  Slight  areas  of 
impaired  resonance  can  be  mapped  out  better  when  approaclied  from  the 
normal  resonant  lung,  and  therefore  percussion  from  Ijclow  npward 
to  a  suspected  apex  is  often  better  than  the  customary  method  of  per- 
cussing from  the  impaired  area  downward  to  the  noruuil. 

As  the  disease  advances,  these  early  signs  are  replaced  by  easily 
demonstrable  dullness,  at  times  accompanied  by  a  tympanitic  overnote 
(tympanitiscJier  Beiklang),  indicating  at  this  stage  not  a  cavity,  as 
some  have  erroneously  supposed,  l)ut  a  mass  of  consolidated  lung  sur- 
rounded by  relaxed  tissue.  Aufrecht  ('05)  expresses  this  well.  He 
says:  "To  conclude  from  a  tympanitic  note  alone  that  there  is  already 
a  destruction  of  tissue  in  the  apex  with  cavitation,  would  be  incorrect. 
We  know  that  in  the  neighborliood  of  a  pneumonically  infiltrated  lobe 
the  percussion  note  is  tympanitic,  and  that  the  same  can  occur  over  an 
apex  with  normal  tissue  in  llie  neighborhood  of  a  considerable  area  of 
condensation." 

This  tympany  can  be  distinguished  from  the  tympany  due  to  a 
cavity  by  the  absence  of  change  of  pitch  (Wintrich's  Schall  Wechsel), 
and  one  should  be  very  careful  before  diagnosing  a  cavity  on  the 
strength  of  dullness  accompanied  by  tympany,  though  marked  tympany 
surrounded  by  a  wall  of  dullness  is  a  very  reliable  cavity  sign.  Where 
unduly  hard  percussion  is  used  a  tympanitic  note  can  frequently  be 
obtained  over  the  apex  by  transmission  from  underlying  bronchi,  but 
as  very  hard  percussion  should  never  be  used  over  the  apex,  such  an 
error  is  easily  avoided. 

When  condensatioft  has  advanced  sufficiently  to  produce  marked 
dullness,  there  will  frequently  be  found  increased  resistance  to  the  finger 
on  percussion,  especially  in  the  suprascapular  regions.  The  dislocation 
of  the  apex  outline,  which  is  present  in  a  slight  degree  in  the  early 
stage,  now  becomes  more  marked.  The  writer  has  found  that  either 
the  inner  or  the  outer  borders  can  be  altered  from  their  normal  position, 
the  outer  coming  inward,  the  inner  moving  outward,  though  Oestreich 
— quoted  by  Aufrecht  ('05) — denies  that  the  outer  border  moves, 
Plowever,  after  having  percussed  out  the  apical  borders  very  carefully 
in  all  patients  for  a  number  of  years,  the  writer  is  positive  of  the  cor- 
nx-tness  of  his  statement,  Avhich  agrees  also  with  the  views  of  Kroenig. 
The  inner  border  is  usually  affected  earlier,  but  dislocation  of  the  outer 
is  often  plainly  marked.  (For  fuller  details  of  the  exact  outlines  and 
the  methods,  see  Diagnosis.)  While  (ioldscheider's  statement  ('07)  that 
the  outlines  as  laid  out  by  Kroenig  do  not  correspond  to  the  exact  ana- 


OBJECTIVE   SIGNS  241 

tomic  apex  is  correct,  Ivrocnig's  lines  being  only  a  projection  of  the 
underlying  resonant  area  on  tlie  skin  of  the  shoulder,  this  does  not  in 
any  way  affect  their  diagnostic  value,  which,  since  changes  in  this  pro- 
jection occur  very  early  aud  very  regularly  in  tuberculosis,  is  consid- 
erable. 

Retraction  of  the  base,  which  is  not  found  in  the  early  stage,  is 
quite  common  in  the  second  stage,  combined  with  limitation  of  motion, 
as  can  easily  be  demonstrated  if  the  outlines  of  the  base  at  rest  and  on 
extreme  inspiration  are  marked  out  by  the  skin  pencil  in  all  cases,  and 
the  information  as  to  the  mobility  of  the  base  yielded  by  this  method 
and  by  the  tluoroscope  is  so  satisfactory  that  the  writer  has  not  made 
use  of  Littcns  diaphragmatic  phenomenon  for  this  purpose. 

When  dullness  becomes  pronounced  the  impaired  resonance  generally 
reaches  below  the  clavicle,  and  the  advancing  border  of  dullness  will 
be  found  very  often  to  run  obliquely  downward  from  the  outer  end  or 
middle  of  the  clavicle  to  the  sternum  at  the  second  or  third  rib,  while 
posteriorly  a  similar  obliquity  will  often  be  found,  though  not  as  com- 
monly as  in  front,  the  dullness  running  from  the  middle  of  the  spine  of 
the  scapula  downward  and  inward  to  the  vertebrae.  The  frequency  of  this 
oblique  position  of  the  dullness  can  be  verified  with  the  fiuoroscope. 

In  examining  the  upper  portion  of  the  lungs  by  percussion,  one 
should  be  careful  always  to  percuss  the  axilla  up  to  its  apex,  as  freciuently 
there  will  be  found  a  spot  of  trouble  here  and  not  elsewhere. 

The  area  of  lung  below  dullness  is  usually  hj'perresonant,  probably 
from  relaxation,  or,  as  Skoda  ('64)  suggests,  from  hyperf unction,  but 
it  must  be  remembered  that  the  anterolateral  aspect  of  the  lung  is  nor- 
mally hyperresonant. 

Where  there  is  extensive  involvement  of  one  lung,  the  other  lung  is 
apt  to  be  hyperresonant  through  increase  of  function.  Absolute  dense 
dullness  over  the  upper  third  of  the  lung  is  rare,  owing  to  the  presence 
of  the  large  bronchi,  and  dullness  here  often  has  a  tympanitic  overnote, 
as  already  stated.  In  the  second  stage,  dullness  will  practically  never  be 
found  at  the  base,  except  in  tlio  rare  cases  where  the  process  begins  in 
this  region  or  where  there  is  a  basal  dry  pleurisy  with  thickening.  Flat- 
ness, except  over  fluid,  is  not  found. 

Basal  dry  pleurisy  should  always  be  looked  for  carefully,  and  in 
many  cases  with  beginning  apical  trouble  on  one  side  slight  dullness 
can  be  found  at  the  anterior  base  of  the  other  lung,  or  the  posterior 
base  of  the  affected  lung,  owing  to  it. 

A  very  usual  location  for  outlying  areas  of  dullness  on  the  anterior 
aspect  of  the  chest  is  the  fourth  interspace,  on  the  left  near  the  axilhiry 
fold,  where  percussion  and  (he  fiuoroscope  will  often  sliow  small  foci 
of  trouble,  separated  from  the  main  focus  above  or  lying  to  the  outer 


242 


SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 


side  and  slightly  above  the  heart.  In  view,  however,  of  the  thickness 
of  the  pectoralis  major  in  this  region  and  the  greater  arching  of  the 
ribs  at  this  point,  one  must  be  very  careful  that  this  does  not  deceive. 

Posteriorly  outlying  areas  of  dullness  are  apt  to  appear  just  above 
or  at  the  angle  of  the  scapula,  especially  on  the  left  side,  while  the  main 
process  is  still  confined  to  the  other  apex.  Another  important  area  of 
dullness  is  between  the  spines  of  the  scapula  and  the  vertebral  column, 
dullness  here  being  a  good  evidence  of  tracheobronchial  adenopathy. 
However,  this  can  be  simulated  by  an  unvisual  muscular  development. 
Anteriorly  such  enlarged  glands  can  produce  areas  of  dullness,  usually 
more  or  less  semicircular  in  outline,  on  one  or  both  sides  of  the  sternum, 
at  the  level  of  the  second  and  third  ribs,  or  over  the  manubrium. 


Fig.  55. — Tuberculosis  of  Tracheobronchial  Lymph  Glands  in  Child  Four 
Months  Old.  Principal  symptom:  severe,  dry  cough,  almost  constant.  Treat- 
ment without  effect.  Pathologically:  small  tuberculous  deposition  in  both 
lungs,  with  area  of  caseous  pneumonia  in  right  middle  lobe.  In  other  organs 
scattered  miliary  tubercles.    (From  Holt,  "  Diseases  of  Infancy  and  Childhood.") 


Enlarged  hroncliial  glands  are,  however,  more  often  missed  by  the 
physician  than  found,  as  can  be  shown  by  the  fluoroscope,  which  has 
demonstrated  them  in  many  cases  where  they  were  entirely  undiscover- 
able  by  percussion.     Ordinarily  they  lie  too  deep  to  be  found,  until  they 


OBJECTI\'E   SIGNS  243 

have  readied  a  very  considerable  size  (Fig.  55).  When  perceivable,  they 
cause  dullness  in  front  much  oftener  than  behind,  and  Barety  ('74) 
ascribes  it  to  their  position  nearer  the  front  than  the  back.  Anteriorly 
they  should  be  percussed  for  by  moving  the  finger  slowly  inward  along 
the  second  and  third  interspaces.  If  they  are  much  enlarged  the  dull- 
ness will  also  be  found  over  the  manubrium. 

When  the  process  reaches  the  third  stage  the  percussion  findings  are 
usually  more  varied,  less  definite  and  less  satisfactory  than  in  the  earlier 
stages.  The  upper  portion  of  the  lung  is  usually  veiy  dull  but  not  flat, 
flatness,  if  present  at  all,  being  generally  found  in  the  middle  or  the 
lower  half  of  the  lung  behind.  The  lower  portion  of  the  lung  in  front, 
especially  in  the  axillary  line,  generally  shows  some  resonance  even  in 
very  advanced  cases,  and  this  area  on  the  fluorescent  screen  generally 
retains  some  degree  of  translucence,  even  in  very  advanced  cases,  unless 
there  is  fluid  or  a  very  thick  pleura. 

As  is  natural,  in  view  of  the  commonness  of  cavitation  in  that 
region,  marked  tympany,  or  even  cracked-pot  resonance,  when  found,  is 
usually  in  the  upper  third  or  half  of  the  lung,  though  if  the  cavities  are 
extensive  tympany  may  extend  over  almost  the  whole  anterior  surface 
of  the  lung.  Posteriorly,  t3'mj)any  is  less  common  than  in  front,  and 
cracked-pot  resonance  very  rare;  and  in  the  writer's  experience  signs  of 
cavitation  of  any  sort  are  rarely  found  behind  below  the  spine  of  the 
scapula,  and  while  autopsies  reveal  in  old  cases  cavities  in  the  lower 
portions  of  the  lungs,  these  W'Ould  rarely  have  time  to  enlarge  suffi- 
ciently to  be  easily  determinable.  In  the  apex,  on  the  contrary,  they 
can  scarcely  be  overlooked  when  they  reach  any  considerable  size.  The 
retraction  of  the  apex  in  the  third  stage  is  extreme,  the  inner  and  outer 
borders  meeting  at  an  angle  whose  apex  lies  below  the  free  border  of 
the  trapezius,  or  the  dullness  may  be  so  marked  that  they  cannot  be 
mapped  out  at  all.  The  base  is  also  often  greatly  retracted,  especially 
if  there  is  much  fibrosis,  and  the  liver  can  be  drawn  upward  and  back- 
ward into  the  thorax,  tympany  occupying  the  normal  location  of  this 
organ,  so  that  by  percussing  downward  over  the  fifth,  sixth,  and  seventh 
ribs  there  is  a  transition  from  normal  or  moderately  impaired  resonance 
to  marked  abdominal  tym])any.  Such  tympany  in  the  site  of  liver  dull- 
ness should,  therefore,  always  suggest  fibrosis,  with  liver  dislocation.  In 
this  stage  also  the  other  lung  is  always  involved  to  a  greater  or  lesser 
degree. 

While  some  degree  of  excavation  occurs  before  this  stage  is  reached, 
and  while  its  determination  at  an  earlier  period  is  more  important  than 
at  this  time,  it  is  in  this  stage  that  one  can  best  study  the  tyj)ical  signs 
of  cavity.  These  vary  greatly  according  to  the  condition  of  fullness  or 
emptiness,  presence  or  absence  of  connection  with  the  air,  the  condition 


244    SYMrTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

of  tlie  walls — such  as  smootlmess,  elasticity,  and  regularity — the  condi- 
tion of  the  surrounding  lung  tissue  as  to  condensation  or  aeration,  and 
es^iecially  according  to  the  size  of  the  cavity.  Cavities  of  less  than  the 
size  of  a  walnut  cannot  be  diagnosed,  and  even  such  must  be  super- 
iicial  if  they  are  to  be  found,  location,  as  Landis  ('06)  found,  being 
more  important  than  size  in  their  discovery.  No  one  has  followed  to 
the  autopsy  table  cases  of  tuberculosis  without  being  convinced  that  cavi- 
tation, in  some  degree,  exists  very  much  earlier  than  is  usually  supposed 
or  than  jihysical  signs  can  determine,  and  that  many  cavities  entirely 
escape  notice.  The  percussion  note  over  a  cavity,  if  the  latter  is  super- 
ficial enough  and  not  too  small  (4  cm.),  may  be  tympanitic,  amphoric, 
or  cracked-pot;  but  if  the  walls  of  the  cavity  are  thick,  or  overlaid  with 
condensed  lung  or  much  thickened  pleura,  there  may  be  only  more  or 
less  dullness,  with  or  without  a  tympanitic  overnote,  and  if  the  cavity 
is  deep  enough,  there  may  even  be  normal  resonance  over  it. 

A  tympanitic  note,  while  the  commonest  percussion  finding  over  a 
cavity,  is  in  itself  by  no  means  diagnostic;  but  a  clear  amphoric  note, 
if  pneumothorax  can  be  excluded,  is  a  positive  sign  of  cavity.  A  cavity 
which  can  give  tympany  when  empty  can  give  dullness  Avhen  full  of 
secretion,  and  such  a  variation  between  dullness  and  tympany  is  an 
excellent  diagnostic  sign.  Some  assistance  in  recognizing  a  cavity  can 
be  obtained  from  the  variation  of  pitch  on  percussion  produced  by 
changes  of  condition  or  position,  this  being  the  Schall  WecJisel  of  the 
Germans. 

Various  tojie  changes  have  been  distinguished.  The  simplest  is  the 
change  in  percussion  note  according  to  the  fullness  or  emptiness  of  the 
cavity,  and  has  been  referred  to  above.  The  next  is  Friedrich's  tone 
change,  in  which  the  note  becomes  higher  on  full  inspiration  and  lower 
on  full  expiration.  The  only  important  changes,  however,  are  those 
which  bear  the  names  of  Wintrich  and  Gerhardt.  The  former  is 
obtained  by  opening  or  closing  the  mouth,  the  note  being  higher  with 
the  mouth  open  and  lower  with  it  closed.  When  this  change  occurs 
only  in  the  recumbent  or  the  erect  position  of  the  body  (intermittent 
AVintrich's  tone  change),  it  is  good  evidence  of  a  cavity,  and  depends 
on  the  fact  that  change  of  position  occludes  or  opens  the  opening  of 
the  cavity  to  the  air.  The  simple  Wintrich's  change  of  pitch  is  of  but 
slight  value  in  the  diagnosis  of  a  cavity,  but  may  be  of  value  in  distin- 
guishing cavity  tympany  from  tympany  due  to  pulmonary  relaxation. 

Gerhardt's  change  of  pitch  is  the  one  produced  over  a  cavity  contain- 
ing fluid,  and  is  brought  about  by  an  alteration  of  position  of  that  fluid 
by  a  change  of  position,  usually  sitting  up  and  lying  down.  Since  most 
cavities  have  their  longest  axis  vertical,  the  note  is  usually  lower  pitched 
on  reclining  and  higher  pitched  on  sitting  up;  but  where  the  long  axis 


OBJECTIVE   SIGNS  245 

of  the  cavity  is  transverse  this  may  be  reversed.  De  Renzi  ('94)  insists 
on  the  importance  of  holding  the  head  straight  in  trying  for  Gerhardt's 
tone  change,  as  changes  of  position  of  the  head  alter  the  dimensions  of 
the  pharyngeal  cavity.  While  this  last  tone  change  is  a  valualjle  sign, 
Leube  ('91)  considering  it  final  if  the  pitch  lowers  on  sitting  up,  or  if 
we  have  intermittent  Wintrich's  tone  change,  which,  after  all,  is  only 
a  modification  of  Gerhardt's,  the  necessary  conditions  are  combined  too 
rarely  to  make  it  of  great  practical  value. 

Cracked-pot  resonance  is  that  peculiar  sound  produced  by  firm  per- 
cussion, without  rebound  of  the  fingers,  over  a  cavity  which  communi- 
cates freely  with  the  air  when  its  contents  are  suddenly  compressed  and 
expelled  by  the  percussion  stroke.  For  its  production  the  mouth  must 
be  open,  but  it  should  be  noted  that  false  cracked-pot  resonance  obtain- 
able over  the  chests  of  children,  or  over  other  very  thin,  elastic  chests, 
can  be  obtained  while  the  mouth  is  closed,  and  that  at  times  large,  super- 
ficial, thin-walled  cavities  give  cracked-pot  resonance  with  the  mouth 
closed.  The  sound  can  best  be  imitated  by  striking  the  back  of  the 
clasped  and  concave  hands  on  the  knee,  wdiich  drives  the  air  out  sud- 
denly from  between  the  fingers.  Skoda  explained  it  as  due  to  a  sudden 
compression  and  expulsion  of  the  air,  and  while  Wintrich  has  given 
another  explanation,  the  former  is  generally  accepted  as  satisfactory. 
Not  only  must  the  cavity  communicate  freely  with  the  air,  but  the  walls 
must  be  thin  and  elastic  so  as  to  be  capable  of  sudden  compression. 

Grancher  and  Corn  11  ('90)  have  noted  that  when  it  cannot  be  ob- 
tained otherwise,  cracked-])ot  resonance  can  be  gotten  if  percussion  is 
practiced  during  expiration.  Unfortunately,  cracked-pot  resonance  is 
oftener  absent  over  cavities  than  present  (T^andis,  '06),  and  is  not  con- 
fined to  excavations,  but  it  may  be  obtained  in  the  area  above  consol- 
idations, or  more  especially  effusions,  as  well  as  in  children  or  others 
with  thin,  weak  chest  walls;  nevertheless,  if  it  occurs  sharply  defined 
and  surrounded  by  an  area  of  dullness,  it  is  pathognomonic,  especially 
if,  as  Leube  ('91)  notes,  it  is  accompanied  by  a  metallic  tone. 

In  the  third  stage  there  are  very  marked  dislocations  of  the  heart, 
due  to  fibrosis  in  the  right  lung,  drawing  the  heart  into  that  side  of  the 
chest,  while  a  similar  condition  in  the  left  lung  can  pull  the  apex  upward 
and  outward  into  the  left  axilla. 

Collections  of  fuid  in  the  chest  in  pulmonary  tuberculosis  are  not  as 
frequent  as  one  would  expect,  and  owing  to  the  very  varied  findings  in 
the  third  stage  are  often  overlooked  until  at  autopsy. 

Eittjtinisrma  is  found  associated  with  tuberculosis  of  the  lungs  quite 
frequently,  desj)ite  the  sup])osed  antagonism  of  the  diseases  (Grancher, 
'90).  The  writer's  cases  which  have  presented  marked  signs  of  a  prece- 
dent empln'sema  have  usually  done  very  well.     It  may  be  either  a  pre- 


246  SYMPTOMATOLOGY   OF    PULMONARY   TUBERCULOSIS 

existing  condition,  in  whicli  case  there  is-  a  typical  barrel-sliaped  thorax, 
with  hyperresonant  or  boxlike  note,  with  decrease  of  the  area  of  cardiac 
dullness  and  increase  of  extension  of  the  lower  borders  of  the  lungs  and 
loss  of  motion  of  the  bases,  or  it  may  be  the  result  of  fibroid  shrinkage, 
with  consequent  narrowing  of  bronchi  and  resistance  to  expiration,  this 
usually  being  found  in  old  third-stage  cases,  and  scattered  here  and 
there  in  the  lung,  so  that  its  diagnosis  is  very  difficult;  or  it  may  sur- 
round healed  apical  lesions,  partly  or  even  entirely  masking  tlie  dullness 
they  produce,  or  rejjlacing  it  by  a  nearly  or  quite  normal  percussion  note. 

The  percussion  in  cases  which  are  improving  shows  a  gradual  lessen- 
ing of  extent  in  tlie  areas  of  impaired  or  modified  resonance,  with  less- 
ening or,  in  very  incipient  cases,  disa])])earance  of  dullness  or  impair- 
ment and  reexpansion  of  dislocated  apical  outlines,  but  pronounced  areas 
of  dullness  never  return  to  a  nonual  percussion  note,  and  some  dullness 
and  dislocation  can  be  found  long  after  all  symptoms  have  entirely 
ceased.  The  limitation  of  motion  of  the  base  can  greatly  lessen,  but 
does  not  often  disappear  entirely.  Over  healing  cavities  tympany  may 
gradually  lessen,  and  finally  disappear  if  the  cavities  are  small  enough 
and  shrinkage  is  very  com])lete. 

AuscvUatory  percussion  the  writer  has  not  found  of  value,  and  he 
has  secured  from  the  more  usual  methods  all  the  information  it  can 
offer.  In  a  careful  review  of  tlie  various  modifications  of  auscultatory 
percussion  by  Kantorowicz  ('OC),  he  comes  to  similar  conclusions,  and 
it  can  safely  be  stated  that  in  the  examination  of  the  lungs  in  pulmonary 
tuberculosis  it  can  be  neglected. 

Auscultation  is  the  most  delicate  and  acute  means  of  recognizing 
the  presence  of  tubercle  in  the  lung,  but  it  is  to  be  regretted  that  as  a 
consequence,  and  because  its  technic  is  more  easily  mastered  than  that 
of  percussion,  the  other  steps  of  a  pliysical  examination  are  too  often 
hurried  through  in  a  perfunctory  way,  while  all  attention  is  placed  on 
auscultation.  Tliis  very  common  error  deprives  the  physician  of  many 
invaluable  aids  and  hints  given  by  the  earlier  steps  of  a  regular  exam- 
ination. A  correct  diagnosis  may,  it  is  true,  often  l)e  arrived  at  by 
auscultation  alone,  but  a  complete  one  can  only  be  reached  by  a  careful 
synthesis  of  all  the  facts  yielded  by  each  step  in  the  examination,  and 
a  neglect  of  any  one  of  them  can  only  lessen  the  accuracy  of  the  result, 
and  while  such  an  incomplete  examination  may  enable  one  to  make  a 
correct  diagnosis  of  a  fairly  advanced  case,  it  is  unreliable  in  those  early 
cases  where  certainty  is  most  needed.  In  the  majority  of  cases  each  new 
step  of  the  examination  will  develop  some  slight  or  more  marked  devia- 
tion from  the  normal  standard  which  is  often  most  suggestive,  and  a 
summation  of  all  these  slight  alterations  Avill  generally  enable  one,  before 
auscultation  has  been  reached,  to  get  a  fair  idea  of  the  seat  and  nature 


OBJECTIVE   SIGNS  247 

of  the  trouble,  which  this  last  and  most  delicate  step  will  confirm  and 
increase. 

Cases  in  which  every  step  except  auscultation  yields  absolutely  nega- 
tive results  will  be  found,  but  only  very  rarely,  and  among  the  most 
incipient  cases.  Eemembering  the  patliology  of  early  tubercle  of  the 
lung,  the  few  scattered  foci  of  peribronchial  infiltration  in  the  apex 
involving  the  vestibule  of  the  alveolus  and  surrounded  by  much  normal 
lung  tissue,  it  Avill  be  evident  that  marked  changes  in  the  respiratory 
nnirmur  in  inci])ient  cases  will  not  be  found.  At  this  time  the  apex, 
supra-  and  infraclavicular  fossfe,  superspinous  fossae,  and  interscapular 
regions  will  alone  give  any  auscultatory  changes. 

The  alterations  physically  determinable  in  the  breath  sounds  in  early 
tuljerculosis  consist  of  slight  modifications  of  the  normal  pitch,  intensity, 
duration,  and  rhythm  of  the  inspiratory,  and  a  little  later  of  the  expir- 
atory murmur  over  the  apices,  rales  in  the  very  incipiency  of  tubercu- 
losis being  generally  absent.  To  recognize  these  early  changes  it  is 
essential  first  to  study  each  phase  of  respiration,  the  inspiratory  and 
expiratory,  separately,  concentrating  attention  on  the  one  to  the  exclu- 
sion of  the  other,  comparing  that  of  one  side  with  that  of  the  other,  and 
then  comparing  inspiration  with  expiration  on  the  same  side.  This  I 
would  call  single-phase  auscuUation;  it  was  developed  by  CTrancher, 
one  of  the  greatest  of  auscultators,  and  a  thorough  experience  with  it 
has  convinced  the  writer  of  its  importance  and  of  its  great  superiority 
over  other  methods  in  the  recognition  of  early  changes  in  tuberculosis. 

Such  single-phase  auscultation  will  demonstrate  that  the  earliest 
changes  are  inspiratory,  a  fact  which  until  recently  was  totally  over- 
looked by  the  best  authorities,  as  a  reference  to  the  works  of  Skoda, 
Walsh,  Flint,  Barth  et  Roger,  Euehle,  Vierordt,  Leube,  and  others  will 
demonstrate.  Those  expiratory  changes  which  were  long  regarded  as 
the  earliest  signs  (Euehle,  '87)  follow  with  the  increase  of  involvement, 
and  as  consolidation  appears  merge  into  bronchovesicular  and  bronchial 
breathing.  However,  thanks  to  the  work  of  Grancher,  the  more  recent 
authors  now  recognize  the  priority  of  inspiratory  changes  (Turban, 
Sokolowski,  Sahli,  Fraenkel,  de  Renzi,  Babcock,  etc.).  It  should  be 
noted  here  that  there  is  no  auscultatory  phenomenon  which  of  itself  is 
pathognomonic  of  pulmonai^y  tuberculosis,  and  the  alterations  found 
speak  for  certain  changes  in  the  pulmonary  tissue,  which  may  or  may 
not  1)0  due  to  tuberculosis,  and  only  by  their  locality,  persistence,  and 
association  icith  other  symptoms  do  they  acquire  diagnostic  value,  and 
that,  as  W.  Walsh  ('71)  says:  "The  value  of  these  states  of  respiration 
is  directly  as  the  limitation  of  the  area  in  which  they  are  discernible." 

Auscultation  of  the  First  St.^ge. — The  earliest  change  is  the 
"  rough  "  vesicular  respiration,  or,  since  it  is  more  descriptive,  granu- 


248  SYMPTOMATOLOGY   OF   PULMONARY  TUBERCULOSIS 

lar  respiration,  the  term  used  by  Woillez.  This  is  the  respiration  rude 
et  grave  of  G rancher  and  other  Frencli  authors  and  tiie  raulies  Athmen 
of  Dettweiler  and  Turban.  Until  (juile  recently  it  has  been  confounded 
with  harsh,  sharp,  or  puerile  respiration,  with  which  it  has  nothing  to 
do  (Sahli,  '02).  It  is  related  to  interrupted  respiration  and  pr(jl)ably 
due  to  sligiit  narrowing  or  uneven  surface  of  the  bronchioles  (Ijy  tutjer- 
cles  here  located),  into  which  the  alveoli  open  and  where  the  normal 
vesicular  murmur  is  formed  in  health  ((irancher,  'DO),  or,  accoi'ding 
to  Turban  ('99),  to  a  rapidly  interrupted  entry  of  air  into  the  alve- 
oli surrounding  the  tuberculous  deposits.  Thus  it  is  always  an  evi- 
dence of  parenchymatous  troul)le.  The  respiratory  murmur  is  rough 
and  low-pitched,  and  it  is  nuide  up  of  a  succession  of  very  sliort  sounds, 
as  though  snuill,  soft  granules  of  fine,  wet  sago  were  being  rolled  over 
each  other. 

When  the  sounds  become  larger  and  separated  from  each  other  by 
distinguishable  intervals,  tlie  ear  ])erceives  them  as  interrupted  respira- 
tion or  as  numerous  fine  moist  rales. 

As  there  is  always  difficulty  in  conveying  by  words  a  correct  impres- 
sion of  a  given  sound,  and  as  a  good  understanding  of  it  is  essential  to 
its  recognition,  and  as  it  is  not  described  in  many  of  the  current  text- 
books, or  is  confounded  with  other  types  of  breathing,  it  may  be  well  to 
quote  a  few  descriptions  of  it  by  other  authors. 

Grancher  ('90,  p.  98),  who,  while  not  the  father  of  the  term,  is  the  one 
who  has  done  most  to  develop  the  iniportanee  of  this  type  of  breathing, 
says:  "The  ear  gets  the  impression  of  a  column  of  air  which  glides  (f/lisse) 
with  rubbing  over  an  irregular  and  narrowed  (rcfrecie)  surface."  Turban 
('99),  who  was  one  of  the  first  Germans  to  recognize  it,  describes  it  as  "  a 
series  of  short,  qviickly  recurring  sounds,"  and  adds,  "  it  depends  on  their 
rapidity  and  strength  whether  the  ear  can  differentiate  them  into  rales 
or  not,"  and  further  notes  that  they  recall  to  him  the  rapid  vibrations 
of  the  hammer  of  an  induction  coil.  Sahli  ('02)  speaks  of  it  as  "  an  im- 
pure, slightly  uneven  {holperiges)  vesicular  sound,  which  now  and  then 
gives  the  impression  as  if  adventitious  sounds  were  mixed  with  the  vesicu- 
lar sounds,"  and  adds,  "  if  these  adventitious  sounds  can  be  plainly  dis- 
tinguished from  the  respiratory  murmur  we  have  rales,"  and  ascribes  it 
either  to  uneven  respiratory  excursions,  to  a  plugged  bronchus,  or  to  the 
presence  of  secretion  in  the  bronchioles.  Cassaet  ('06)  says:  "The  air 
seems  to  be  constantly  passing  over  slightly  elevated  obstacles  by  which 
it  is  constantly  broken,  and  this  sensation  of  obstructed  progress  gives  the 
idea  of  a  rough  unpolished  surface."  De  Renzi  ('94)  describes  it  as  "  an 
abnormal  respiration  consisting  of  successive  small  irregular  impulses,  and 
corresponding  to  the  tactile  impression  one  gets  when  one  rubs  the  beads 
of  a  rosary  together  with  the  fingers  (ircnn  man  die  Gliedcr  eines  Rosen- 
kranzes  mil  den   Fingern   aneinander   reibt)."      Mannheimer    ('06)    says: 


OBJECTIVE   SIGNS  249 

"  Instead  of  being  heard  as  a  continuous  breezy  sound  it  will  be  perceived 
to  consist  of  a  series  of  short  puffs  following  each  other  in  rapid  suc- 
cession." 

This  type  of  respiration  is  most  common  in  the  supras])inous  fossa, 
in  the  claviculo-sternal  angle,  and  in  tlic  supraclavicular  fossa,  in  the 
order  named,  Init  it  can  often  he  found  farther  down  in  the  lung  on 
the  advancing  border  of  the  disease,  and  its  appearance  in  isolated  spots 
often  gives  early  warning  of  the  development  of  a  new  focus. 

Grancher  considers  it  most  common  in  the  left  infraclavicular  space, 
but  in  the  writer's  cases  it  has  been  commoner  on  the  right.  While, 
like  all  other  auscultatory  signs,  it  is  not  in  itself  absolutely  pathogno- 
monic of  tubercle,  it  is,  when  limited  to  the  apex,  fixed  and  not  transi- 
tory, slowly  increasing  in  intensity  until  expiration  is  involved  as  well 
as  inspiration,  and  in  conjunction  with  other  symjitoms  a  sure  sign  of 
beginning  tuberculous  involvement.  Grancher  believes  that  where  it  is 
found  at  the  apex,  one  will  often  also  find  it  at  the  base  of  the  same 
lung,  an  observation  the  writer  has  not  been  able  to  verify. 

Next  in  earliness  of  a])pearance,  but  not  in  diagnostic  value,  is  feeble 
breathing,  a  lessening  of  the  intensity  of  the  sounds  both  on  inspiration 
and  expiration.  It  may  be  either  vesicular  or  slightly  rough,  and  inspi- 
ration is  feebler  than  expiration  (Herard,  C'ornil,  and  Ilanot,  '88).  It 
is  due  to  obstruction  to  the  flow  of  air  l)y  tubercles  or  mucus.  The 
writer  has  found  it,  in  the  small  areas  in  which  alone  it  is  of  value, 
commonest  in  the  left  lung  above  the  clavicle.  It  can,  however,  be  pro- 
duced by  so  many  conditions  (by  limited  functional  activity,  as  in  adhe- 
sive pleurisy,  pain,  emphysema,  obstruction  or  nar^-owing  of  ])ronchi ;  or 
by  imperfect  conduction  of  sound,  as  from  thick  pleura,  fat,  or  muscle) 
that  it  needs  to  be  limited  strictly  to  the  apex  and  persistent  after  cough, 
but  if  these  conditions  are  satisfied  it  is  suggestive  of  tuberculization. 
At  the  base  behind  it  suggests  a  thickened  pleura. 

Interrupted  hreathing  (wavy,  jerking,  cog-wheel  l)rcathing,  respira- 
tion saccadl'e  of  the  French,  saccardirtes  Atlimcn  of  the  Germans)  is  a 
form  of  respiration  in  which,  instead  of  the  smooth,  even  sound  of  the 
normal  respiratoiy  muiiiiur,  the  inspiratory,  and  much  more  rarely  the 
expiratory  sound,  is  divided  by  short  pauses  into  successive  periods, 
which  give  the  impression  as  though  the  column  of  air  were  alternately 
arrested  and  freed,  and,  according  to  Sahli  ('02),  it  is  due  to  a  valve- 
like action  of  swollen  mucous  membrane  or  secretion  in  the  smaller 
tubes;  or,  according  to  others,  to  the  uneven  contraction  of  the  lung 
from  the  presence  of  tubercles;  or,  as  Kuehle  ('87)  thinks,  to  the  rub- 
bing of  subpleural   tubercles. 

While  it  lias  been  considered  by  nuiny,  notably  Peter,  as  a  very  early 


250    SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

sign,  the  writer  does  not  believe  that  an  early  diagnosis  will  often  depend 
on  the  discovery  of  this  type  of  respiration,  and  he  has  not  found  it  as 
commonly  over  the  apex  as  in  the  claviculo-sternal  angle  and  at  the  right 
base  behind,  or  on  the  advancing  border  of  evident  lesions.  It  is  very 
frequent  behind,  between  the  angle  of  the  scapula  and  the  base.  It  is 
best  auscultated  during  quiet  breathing,  as  deep  breathing  has  sufficient 
force  to  overcome  the  obstruction  it  produces  and  thus  remove  it  (Vie- 
rordt,  '8!)).  Interruptions  in  the  respiratory  jhythm  may  be  produced 
and  real  interrupted  breathing  simulated  by  several  other  conditions. 

The  most  deceptive  of  these  is  irregular  muscle  contractions  in  nerv- 
ous, timid,  or  chilly  subjects,  in  whom  it  is  common.  In  such  cases  it 
will  be  heard  very  extensively,  especially  in  front.  Adhesive  pleurisy 
or  pain,  by  causing  irregular  expansion  of  the  lung,  may  also  cause  it, 
but  the  interrupted  breathing  so  caused  can  easily  be  distinguished  from 
the  genuine.  The  heart  action  may  also  simulate  it  in  inspiration,  but 
will  not  deceive  the  careful  auscultator. 

Grancher  ('!><))  thinks  real  interrupted  breathing  can  be  distin- 
guished from  all  these  forms  by  the  fact  that  in  them  the  vesicular 
murmur  is  normal,  while  in  tuberculosis  it  is  generally  rough  or  weak, 
but  See  ('84)  considers  that  it  can  be  pure  in  tuberculosis,  a  fact  which 
the  writer  has  noted.  Like  feeble  breathing,  its  strict  localization  to  a 
small  area  is  essential;  heard  over  large  areas  it  is  certainly  false. 

Harsh  respiration  {verschdrft  vesicular),  as  already  noted,  is  very 
often  confounded  with  rough  respiration,  so  that  it  is  well  to  define  it. 
According  to  W.  Walsh  ('71),  "both  sounds  have  lost  their  natural 
softness,  a  peculiar  dryness  accompanies  them,  the  breezy  character  of 
health  is  exchanged  for  one  sharper  and  more  blowing,  which  is  gen- 
erally more  marked  in  expiration  than  in  inspiration.  The  intensity 
of  the  respiratory  sound  ai)})ears  augmented  from  the  superadded  char- 
acter and  its  duration  is  increased.  Both  these  latter  properties  may 
be,  and  commonly  are,  unaffected  in  the  inspiratory  sound.  ...  In 
harsh  respiration  tlie  expiratory  sound  commonly  alone  suffers  clumge 
of  quality." 

Until  recent  years  harsh  respiration  with  prolonged  expiration  was 
considered  the  commonest  early  sign  of  tuberculosis  of  the  apex,  as  a 
reference  to  any  standard  text-book  of  fifteen  years  back  will  show 
(Euehle,  '87),  a  view  first  advanced  in  1833  by  Jackson,  of  Boston 
(Flint,  '5G)  ;  but  such  have  been  the  advances  in  knowledge  of  the 
early  pathology'  and  diagnosis  of  tuberculosis  that  it  is  now  recognized 
that  harsh  respiration  is  not  as  early  as  rough,  feeble,  or  interrupted 
respiration.  Grancher  ('90),  who  distinguishes  a  stage  of  germination, 
considers  that  the  appearance  of  this  type  of  breathing  marks  the  end 
of  this  stage,  and  is  accompanied  by  dullness  on  jjercussion,  and  that 


OBJECTIVE   SIGNS  251 

it  succeeds  rough,  low  inspiration,  and  tends  to  pass  gradually  into 
bronchovesicular  and  bronchial  breathing,  with  harsh  inspiration  and 
expiration. 

Nevertheless,  since  few  patients  are  seen  in  the  very  incipiency  of 
the  trouble,  harsh  respiration,  esjaecially  in  the  expiratory  phase,  will  be 
the  change  ordinarily  found  by  the  physician  at  his  first  examination 
in  the  majority  of  incipient  cases,  and  if  it  is  confined  to  one  apex,  and 
heard  on  quiet  hrcalhiiig,  it  has  great  value  in  diagnosis,  and  Sokolow- 
ski  ('06)  believes  that  in  this  location  it  is  only  heard  in  tuberculosis. 
However,  the  writer  would  note  two  exceptions  to  this  statement;  he 
has  found  it  quite  often  at  the  apex  after  grippe  pneumonias,  especially 
in  children,  where  it  may  be  quite  persistent  for  some  weeks,  arousing 
fears  as  to  the  possible  development  of  post-grippal  tuberculosis,  but 
finally  clearing  up  completely.^ 

The  harshness  is  due  to  narrowing  of  the  bronchi  and  condensation 
of  lung  tissue,  and  demands,  therefore,  a  relatively  extensive  lesion  for 
its  production,  so  that  when  it  is  found  the  case  is  no  longer  incipient 
in  the  strictest  sense.  Unlike  rough,  feeble,  or  interrupted  breathing, 
it  is  heard  most  often  at  the  extreme  apex  in  front,  and  to  a  less  degree 
at  the  extreme  apex  behind,  or  in  the  clavieulo-sternal  angle. 

While  commonest  at  the  right  apex,  the  examiner  must  never  forget 
that  such  a  type  of  breathing  is  said  to  be  normally  found  in  a  slight 
degree  at  this  point,  especially  in  anemic  young  girls,  and  hence  that 
its  value  is  greatest  when  found  at  the  left  apex,  and  in  men  (Walsh, 
'71).  At  the  same  time,  since  tuberculosis  in  young  girls  often  begins 
as  a  chlorosis,  and  as  the  writer  has  seen  not  a  few  sucli  girls  who  also 
had  incipient  right  apical  trouble,  he  would  advise  that  not  too  great 
weight  be  laid  on  the  normal  appearance  of  this  type  of  breathing  at 
the  right  apex  if  it  be  found  in  a  slender,  pale  young  girl,  with  other- 
wise suspicious  symptouiS,  and  be  not  too  quickly  passed  over  as  normal 
to  this  region,  but  tliat  such  a  one  be  carefully  watclied  and  studied 
before  a  diagnosis  of  tuberculosis  is  rejected.  Harsh  respiration  in 
tuberculosis,  when  it  once  appears,  may  be  most  persistent,  unlike  the 
inspiratory  changes  which  soon  alter,  and  it  often  persists  for  years 
after  the  disease  is  arrested. 

Prolonged  expiration,  or  prolonged  and  feeble  expiration,  in  the 
absence  of  harshness,  is  not  of  great  value.  Sokolowski  ('06),  however, 
considers  that  when  strictly  localized  to  an  apex,  and  heard  on  quiet 
breathing,  it  is  a  valuable  sign,  but  Walsh  holds  the  opposite  view,  as 

•  The  writer  has  also  found  it  along  with  other  rational  symptoms  in  certain  cases 
of  sy]5hilis  of  the  apex,  and  persistent  for  long  periods,  and  entirely  undistinjruishablc 
from  tuberculosis  until  the  patient  was  placed  on  mixed  treatment,  when  it  cleared 
up  rapidly  and  permanently. 


252  SYMPTOMATOLOGY   OF    PULMONARY  TUBERCULOSIS 

does  Flint  ('75),  who  says:  "Among  cases  in  which  a  tuberculous 
deposit  exists  it  is  exceedingly  rare  that  diagnosis  hinges  exclusively  on 
prolonged  expiration,  and  it  would  certainly  be  unsafe  to  base  a  posi- 
tive diagnosis  on  tliis  sign  alone."  However,  as  an  evidence  of  com- 
pensatory emphysema  around  a  healing  focus  it  is  of  great  value. 

Puerile  {exaggerated,  supplementary)  breathing.  While  this  type 
of  breathing  will  at  times  be  found  over  the  apex  in  incipient  tubercu- 
losis, it  is  not  a  reliable  early  sign,  and  is  commoner  over  the  healthy 
lung  as  a  result  of  compensatory  action,  or  in  the  area  around  a  focus 
of  trouble.  The  increased  intensity  chiefly  involves  expiration,  which 
is  also  prolonged,  but  it  does  not  lose  its  vesicular  quality  nor  its  pitch. 

Finally,  in  speaking  of  early  signs,  one  should  note  the  undue  trans- 
■ntission  of  heart  sounds  to  the  apex  (Brown,  L.,  '04  A).  When  the  heart 
sounds  are  distinctly  audible  over  the  right  a[)ex  it  speaks  for  a  con- 
densation of  the  underlying  lung,  and  is  a  very  valuable  sign.  AVhea 
heard  at  the  left  apex  the  sign  is  not  of  great  value;  and  in  any  case,  if 
the  heart  is  beating  hard,  the  value  of  this  sign  is  greatly  lessened.  At 
times  other  small  areas  of  the  lung  are  found  in  which  the  heart  sounds 
are  unduly  transmitted,  especially  in  tiie  bases  behind,  and  will  thus 
direct  attention  to  spots  of  congestion,  and  probably  of  consolidation, 
which  might  otherwise  easily  be  overlooked. 

The  study  of  vocal  resonance  in  the  earliest  stage  of  the  disease  is 
of  little  value,  but  when  there  is  slight  percussion  dullness  and  harsh, 
prolonged  expiration  it  is  usually  intensified;  but  here,  again,  as  in  so 
many  other  instances,  its  value  is  slight  unless  it  is  very  intense  or  unless 
it  is  found  at  the  left  apex,  owing  to  the  noi-mal  increase  of  vocal  reso- 
nance over  the  right  apex.  In  men  with  very  strong  voices  it  is  value- 
less, and  in  patients  with  very  weak  voices  or  hoarseness  it  cannot  be 
tested. 

Rales  cannot  justly  be  considered  as  signs  of  the  incipiency  of  tuber- 
culosis, although  formerly  they  were  so  considered,  and -some  authors 
still  so  regard  them.  G rancher  ('90)  considers  them  a  sure  sign  of 
softening,  but  they  will  not  generally  be  found  until  the  first  stage  is 
well  advanced,  and  one  should  under  no  circumstances  wait  until  they 
develop  before  nuiking  a  diagnosis.  At  the  same  time,  while  generally 
a  sign  of  more  advanced  trouble,  certain  kinds  of  rales,  if  the  process  is 
developing  actively,  can  be  found  very  early  in  the  disease,  while  if  its 
course  is  very  chronic  they  will  7iot  be  heard  until  later.  A  few  fine 
sibilant  rales  can  frefpiently  be  found  over  the  posterior  aspect  of  the 
apex,  or  less  commonly  in  front,  at  the  very  end  of  inspiration,  but 
while  they  speak  for  a  localized  broncliitis,  they  are  not  of  great  diag- 
nostic value,  unless  i)ersistent. 

Isolated  pleuritic  friction  sounds    (Flint,  '75)    over  an  apex,  while 


OBJECTIVE   SIGNS  253 

not  common,  are  suggestive  of  a  tuberculous  apical  pleurisy,  and  acquire 
great  importance  when  confirmed  by  other  slight  changes.  At  times 
they  may  be  mistaken,  if  fine  enough,  for  crepitations. 

Of  very  great  importance  are  the  "  dry  crackles "  of  Walsh,  the 
cracquements  sec  of  the  French.  As  there  is  much  confusion  in  the 
use  of  terms  descriptive  of  adventitious  sounds,  and  as  such  dry  crackles 
are  closely  related  to  crepitant  rales,  a  quotation  from  the  description 
given  by  Walsh,  a  master  in  the  description  of  physical  signs,  will  be 
of  value.  The  dry  crackle  "  is  composed  of  a  succession  of  minute,  dry, 
short,  sharp  cracklings,  feiu  in  number,  rarely  exceeding  three  or  four 
in  a  respiration,  coexisting  exclusively,  or  almost  exclusively,  with  inspi- 
ration, though  in  very  rare  cases  most  obvious  in  expiration  .  .  .  perma- 
nent (that  is,  not  removed  by  cough)  in  the  great  majority  of  cases, 
after  its  character  has  once  been  perfectly  developed,  .  .  .  passing  into 
the  moist  crackle."  The  crepitant  rtile  Walsh  defines  as  occurring  "  in 
puffs  more  or  less  pronounced,  but  rapidly  evolved,  composed  of  a 
variable,  sometimes  immense,  number  of  sharp  crackling  sounds,  all 
perfectly  similar  to  each  other,  conveying  the  notion  of  minute-sized, 
dry  bubbles,  coexisting  exclusively,  except  in  rare  cases,  with  inspiration, 
and,  once  so  established,  remaining  persistent  until  superseded  by  other 
phenomena." 

Crepitant  rales  are  not  strictly  dry,  being  probably  generally  pro- 
duced by  the  separation  of  the  walls  of  alveoli  which  are  stuck  together 
by  secretion  (hence,  sometimes  heard  after  very  deep  breath  in  nor- 
mal individuals  and  called  "atelectatic  rales")  or  by  pleural  frictions 
(Leaming)  ;  but  they  certainly  are  not  really  moist  in  the  sound  they 
give  to  the  ear,  which  is  distinctly  a  dry  sound.  When  heard,  true 
crepitant  rales  speak  for  small  areas  of  pneumonic  infiltration. 

Recurring  to  Walsh's  excellent  description,  which  agrees  with  that 
of  Flint  ('56),  it  is  evident  that  the  "dry  crackles"  of  Walsh,  or  the 
iracqiwments  sec  of  Fournet  and  Grancher,  difi^er  from  crepitant  rales 
only  in  that  the  former  are  few  in  number  and  isolated,  the  latter  very 
numerous  and  in  salvos.  It  would  tend  to  clearness  in  nomenclature  if 
the  former  were  simply  spoken  of  as  isolated  crepitant  rales.  If,  as 
Fox  notes,  tuberculosis  is  ushered  in  by  hemoptysis,  the  first  rales  heard 
will  be  moist,  but  with  this  exception,  although  such  excellent  authori- 
ties as  L.  Brown  ('04  A)  and  Babcock  ('07)  difl'er  from  the  writer's 
opinion,  he  is  satisfied  that  in  the  very  incipiency  moist  rales  will  not 
be  heard,  the  typical  rale  being  generally  a  dry  crackle,  though  if  a 
small  area  of  pneumonia  exists  there  may  be  crepitant  rfdes,  an  ojiinion 
that  is  supported  by  many  of  the  best  authorities,  such  as  Fox  ('•'!), 
W.  Walsh  ('71),  Grancher  ('i)O),  and  Flint  ('of.). 

Limited  to  one  spot,  es])e(ially  in  the  apex,  but  at  times  in  other 


254  SYMPTOMATOLOGY   OF   PULMONARY  TUBERCULOSIS 

areas,  persistent  after  cougli  and  not  transitory,  dry  crackles  are  in  them- 
selves alone  presumptive  evidence  of  tuberculosis,  and  when  accompanied 
by  breath  changes  and  rational  symptoms  justify  such  a  diagnosis.  In 
other  spots  than  the  apex  they  are  less  to  be  relied  on,  but  are  increas- 
ingly suspicious  in  proportion  to  their  persistence.  It  mvist  be  recalled, 
however,  that  at  first  they  will  not  be  heard  on  quiet  breathing,  but  only 
on  deep  breathing,  or  after  cough,  and  thus  it  is  important  in  all  sus- 
picious cases  to  make  a  patient  cough  at  the  end  of  a  deep  breath,  or 
just  before  one,  if  they  are  to  be  heard.  If  heard  on  quiet  breathing. 
Brown  considers  the  case  no  longer  an  incipient  one. 

The  dry  crackle  tends  by  degrees  to  become  a  moist  crackle  (W. 
Walsh,  '71),  the  rracquement  hutuidc  of  Fournet,  and  with  this  change 
it  invades  expiration  as  well  as  inspiration.  Here,  again,  in  the  in- 
terest of  simplicity  of  nomenclature,  it  seems  that  the  term  "  moist 
crackle  "  should  be  given  up,  since  a  reference  to  Fournet  or  Walsh's 
descriptions  will  show  that  it  is  simply  a  fine  moist  rtde  ("  subcrepi- 
tant "  rale).  'J'o  (|uote  Walsh:  "A  series  of  clicking  sounds — a  few  in 
number — of  moderate  size,  occurring  during  both  respiratory  move- 
ments, but  with  greater  regularity  and  distinctness  of  character  in  inspi- 
ration, aiul  eventually  passing  into,  or  rather  superseded  by,  ronchi  of 
the  buljbling  class."  In  the  latter  part  of  the  first  stage  a  few  such  fine 
moist  rtlles  will  be  found,  and  Fournet  believed  that  the  change  from  a 
dry  to  a  moist  sound  did  not  occur  until  from  twenty  days  to  three 
months  had  passed.  Lampadarios,  quoted  by  Cornet,  and  Stanton,  of 
Philadelphia  (personal  reference),  consider  that  rales  not  otherwise  dis- 
coverable may  at  times  be  found  if  the  patient  is  reclining.  Again,  rales 
are  more  apt  to  be  heard  early  in  the  morning,  and  if  not  found  at  the 
usual  time  of  examination,  it  may  be  necessary  to  auscultate  the  patient 
on  waking  and  at  various  times  in  the  day. 

H.  Anders  ('07)  quotes  Cybulski  as  to  (he  diagnostic  value  of  oral 
auscultation  for  fine  crepitations  in  early  cases,  the  physician  auscul- 
tating in  front  of  the  patient's  mouth  during  quiet  breathing,  the 
sounds  being  heard  botb  on  expiration  and  inspiration.  While  the 
writer  has  verified  this  in  moderately  advanced  cases,  he  has  not  been 
able  to  do  so  in  very  early  ones. 

It  cannot  be  too  emphatically  insisted  that  nlles,  to  have  any  diag- 
nostic value  in  early  tuberculosis,  must  be  strictly  localized,  in  the 
majority  of  cases  to  the  apex,  and  permanent ;  transitory  rales  having  no 
value  at  all,  though  rales  may  be  absent  temporarily. 

Auscultation  of  the  Second  Stage. — As  the  process  spreads  and 
consolidation  appears,  with  beginning  softening,  the  auscultatory  find- 
ings intensify  and  multiply,  the  most  typical  being  changes  in  expira- 
tion.    The  breath  sounds  become  bi'oncliovesicular  and  finally  bronchial. 


OBJECTIVE   SIGNS  255 

with  the  appearance  of  what  have  been  very  generally  called  subcrepitant 
rales,  an  unfortunate  term  for  fine  and  medium-sized  moist  rales.  The 
expiratory  murmur  becomes  increasingly  prolonged  and  harsh,  inspira- 
tion begins  to  rise  in  pitch,  and  there  is  bronchovesicular  respiration, 
so  named  by  Flint.  This  type  of  breathing  is  due  to  the  presence  of 
consolidated  areas  of  considerable  extent  in  the  midst  of  normal  lung 
tissue,  the  tubular  or  bronchial  breathing  produced  in  the  diseased 
bronchi  and  surrounding  infiltrated  lung  being  modified  by  being 
mingled  Avith  the  normal  vesicular  sounds  of  the  overlying  tissue. 

Inspiration  is  less  vesiciilar  than  in  health,  being  a  mixture  of  nor- 
mal vesicular  breathing  with  the  tubular  quality  of  bronchial  breathing. 
Its  pitch  is  raised  and  it  is  not  continuous  with  expiration,  being  short- 
ened, while  the  resultant  inspiratory  pause  increases  with  the  increase 
of  the  consolidation,  and  the  advance  toward  pure  bronchial  or  tubular 
quality.  The  name  bronchovesicular  is  so  appropriate  that  it  is  to  be 
regretted 'that  the  term  indeterminate  {unbe^tinvmt,  Skoda,  '64),  a 
most  unsatisfactory  and  undescriptive  term,  has  been  used  so  largely, 
and  the  writer  believes  with  Turban  ('99)  that  it  should  be  abandoned. 
When  finer  distinctions  are  to  be  made  the  term  vesiculobronchial,  as 
suggested  by  Da  Costa,  can  be  applied  to  the  earlier  stage  in  which  the 
vesicular  element  predominates,  bronchovesicular  to  that  in  which  the 
bronchial  element  is  most  prominent.  This  type  of  breathing  is  of  very 
great  diagnostic  value  and  speaks  for  a  considerable  tuberculous  deposit 
in  the  apex.  While  slight  degrees  of  vesiculobronchial  Ijreathing  may 
be  found  at  the  right  apex  in  the  normal  lung,  as  noted  by  Flint  ('56), 
the  writer  has  never  found  distinct  bronchovesicular  breathing  in  nor- 
mal lungs,  but  if  vesiculolu'onchial  l)realhlng  is  heard  at  the  right  apex 
it  must  be  pronounecd  to  be  of  significance  in  diagnosis. 

Bronchial  breathing,  except  in  acute  cases  (De  Renzi,  '94)  where 
consolidation  is  rapid,  never  appears  suddenly  in  tuberculosis,  but  de- 
velops out  of  bronchovesicular  breathing,  and  its  presence  evidences 
considerable  consolidation  near  the  surface,  connected  with  the  air  by  a 
bronchus.  In  this  ty))e  of  breathing  all  vesicular  quality  is  lost,  and  the 
respiration  beconu^s  what  the  French  call  a  sotiffie.  It  is  harsh  and 
loud,  inspiration  is  high-pitched  and  prolonged,  and  the  intensity  of 
both  sounds  is  increased,  especially  that  of  expiration,  in  which  phase 
it  is  best  heard,  hut,  owing  to  the  less  intense  consolidation  in  tuber- 
culosis, the  typical  bronchial  breathing  of  pneumonia  is  rarely  found. 

When  the  process  has  gone  far  enough  to  produce  bronchial  breath- 
ing in  one  lung,  auscultatory  changes  are  usually  found  on  the  other 
side,  together  with  exaggerated  I)r(>ath  sounds,  weakened  l)reathing,  or 
the  various  signs  of  early  tuljerculosis,  or  even  bronchovesicular 
Ijreathinsr. 


256    SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

In  tliis  stage  one  M-ill  at  times  find  absent  breath  sounds,  chiefly 
bel)in(l,  Init  a  few  strong  eouglis  will  often  remove  the  mucus  which,  by 
plugging  a  bronchus,  causes  it.  Siljihant,  wliistling  inspiration,  heard 
h)udest  on  eaeli  side  of  the  sternum,  at  tlie  level  of  the  second  rib,  or  be- 
tween the  scapula^  and  transmitted  downward  and  outward,  is  at  times 
found  in  this  stage,  when  enlarged  bronchial  glands  exist,  and  speaks  for 
pressure  on  the  Ijronchi  and  is  a  valualde  diagnostic  sign  of  adenopath3^ 
Usually  one  will  find  along  the  Ijorder  of  the  more  marked  abnormal 
breath  sounds  a  zone  in  which  the  earlier  breath  changes  can  be  heard; 
for  example,  bronchial  breatliing  merging  into  bronchovesicular  breath- 
ing, and  this  into  rough,  feeble,  or  interrupted  breatliing.  The  normal 
occurrence  of  bronchial  breatliing  between  the  scapula  over  the  large 
bronchi  must  not  be  forgotten,  as  it  might  lead  into  error. 

The  typical  nlle  of  this  stage  is  the  small  or  medium-sized  moist  rale, 
due  to  bronchitis  and  softening,  and  which  has  been  unfortunately 
called  subcrepitant,  a  term  wliich  causes  much  confusion.  Cabot  ("05) 
advocates  making  no  distinction  between  the  "'subcrepitant"  and  crepi- 
tant r.lles ;  but  since  the  crepitant  rale  is  essentially  a  dry  rale  in  sound, 
and  the  "subcrepitant"  rale  is  a  moist  ride,  and  the  distinction  of  dry 
and  moist  rales  is  useful  and  justifiable,  this  is  unfortunate,  and  the 
majority  of  recent  authors  distinguish  them  sharply.  Tlie  difficulty  of 
distinguishing  between  the  crepitant  n'lle  and  the  dry  crackle  has  already 
been  referred  to. 

Fine,  moist  rfdes,  AA'hich,  unlike  crepitations  and  dry  crackles,  are 
heard  both  in  inspiration  and  expiration,  appear  over  the  apex  in  the 
end  of  the  first  or  early  in  the  second  stage.  They  are  at  first  limited 
in  area  and  scanty,  and  later  become  more  diffused  and  more  numerous. 
Their  prognostic  significance  is  very  great,  and  while  at  times  they  may 
be  present  for  long  periods  in  favorable  cases  and  over  large  areas,  it 
may,  as  a  rule,  be  said  that  the  number  and  size  of  the  moist  rfdes 
bear  a  fairly  direct  relation  to  the  course  of  the  trouble,  lessening  of 
the  rales  signifying  usually  improvement,  increasing  of  the  rales  signi- 
fying increase  of  trouble. 

Often,  if  the  patient  is  doing  well,  these  rales  will  disappear  for 
long  periods,  appearing  only  at  intervals  when  congestions  occur.  Gen- 
erally the  rales  at  the  apex  are  medium-sized  or  small,  and  Vierordt 
('89)  considers  large  rales  in  this  location,  where  there  are  only  small 
bronchi,  the  most  certain  sign  of  cavity.  At  times  one  will  find  a  single 
persistent  medium-sized  moist  rale,  which  from  its  peculiar  sticky 
quality  has  been  called  a  mucous  click,  and  some  authors  consider  it 
of  great  diagnostic  value.  More  usually  one  will  find  ten,  twenty,  or 
more  fine  or  medium-sized  rales,  not  pronouncedly  moist  and  not  per- 
manentl}'  removed  by  coughing.     As  the  process  advances  the  rales  be- 


OBJECTIVE   SIGNS  257 

come  larger  and  occupy  inspiration  and  expiration  comjoleteh;,  are  more 
numerous,  cover  a  greater  area,  and  are  apt  to  become  resonant  (con- 
sonant, l-Hngend) ,  such  resonance  speaking,  like  bronchial  breathing, 
for  cavity  formation  or  consolidation.  In  this  stage  one  will  very  com- 
monly find  at  the  base,  and  chiefly  at  the  anterior  lateral  base,  on  the 
side  opposite  the  chief  lesion,  signs  of  dr}^  pleurisy,  with  fine  or  medium- 
sized  frictions  reaching  up  as  high  as  the  fifth  rib.  And  when  tlie  fric- 
tions from  below  merge  into  an  area  of  the  lung  showing  dry  or  fine 
moist  rales,  it  is  with  the  greatest  difficulty  that  one  can  determine 
positively  where  the  friction  sounds  end  and  the  rales  begin.  And  when, 
as  in  a  diffused  process,  rales  and  friction  sounds  coexist,  the  difficulty  is 
insuperable. 

Leaming  ('84),  a  brilliant  physical  diagnostician,  was  puzzled  by 
the  distinction  of  fine  frictions  from  crepitant  rales,  and  after  a  number 
of  autopsies  in  which  he  found  that  what  had  apparently  been  typical 
crepitant  rales  were  really  pleural  frictions,  advanced  the  theory  of 
the  pleural  origin  of  the  crepitant  rale.  Most  authors  now  admit 
that  in  this  he  was  in  part  correct.  Certainly  a  distinction  is  often 
impossible.  Trousseau,  recognizing  the  difficulty  of  the  distinction, 
called  such  doubtful  rales  "friction  rfdes  "   (fruttenwuts  rciles). 

On  reading  a  text-book  of  physical  diagnosis  such  a  differentiation 
might  seem  a  simple  matter.  But  unless  the  frictions  are  loud  and  un- 
mistakably pleuritic,  which  is  true  in  only  a  minority  of  the  cases,  none 
of  the  rules  given  will  serve,  the  distinction  being  one  of  the  most 
difficult  the  auscultator  has  to  meet.  The  pleural  friction  is  said  to 
be  increased  by  the  pressure  of  the  stethoscope,  unlike  the  riile,  but  this 
maneuver  will  often  not  prove  of  assistance.  Cough  should  remove  or 
modify  the  rale  and  intensify  the  friction,  and  when  one  can  demon- 
strate this  it  is  a  valuable  sign,  but  is  more  often  absent  than  present. 

Cornet  ('07)  quotes  Prodi  to  the  effect  that  oral  auscultation  inten- 
sifies resonant  rales,  while  pleuritic  frictions  are  weakened  or  not  heard. 
The  fact  that  pleural  sounds  seem  to  be  directl}'  under  the  ear  is  more 
reliable,  but  loud  superficial  rales  can  seem  equally  close.  Pain  is  as 
often  absent  as  present  over  pleuritic  frictions. 

Grancher  ('90)  says:  "  Wben  a  sound  like  a  moist  crackle  or  a 
subcrepitant  rale  is  heard  at  the  end  only  of  inspiration,  and  continues 
into  expiration,  we  can  reasonably  attribute  it  to  the  pleura,  because 
the  large  crepitations  of  pulmonary  or  bronchial  origin  exist  from  the 
beginning  of  inspiration.  Further,  it  is  characteristic  of  almost  all 
light  frictions  that  they  only  commence  in  the  second  part  of  inspira- 
tion, to  continue  during  expiration,  so  that  the  ear  has  a  paradoxical 
sensation  of  sounds  similar  to  mucus  rales,  developed  a  long  time  after 
the  passage  of  air  in  the  bronchioles." 
18 


258  SYMPTOMATOLOGY   OF   PULMONARY  TUBERCULOSIS 

On  the  whole  tlie  writer  believes  that  the  only  two  fairly  reliable 
points  are  clinical  rather  than  physical — the  persistence  of  the  sounds, 
if  pleural,  in  stationary  or  improving  cases,  and  the  fact  that  they  are 
often  found  over  areas  in  cases  where  rales  so  extensive  would  almost 
necessitate  severe  constitutional  symptoms,  yet  in  which  health  is  fair. 

A  young  man,  who  at  the  first  examination  showed  diffused  over  the 
front  of  his  chest  on  the  left  side  numerous  apparently  fine  moist  rales, 
had  been  pronounced  to  be  in  an  advanced  and  almost  hopeless  condition. 
The  total  absence  of  rational  symptoms,  sufficient  to  justify  such  signs, 
led  the  writer  to  suspect  that  they  were  largely  pleural,  but  only  the  sub- 
sequent course  of  the  case,  which  has  been  one  of  very  good  health  and 
working  efficiency  for  years,  showed  that  the  assumption  was  correct. 
Turban's  statement  that  there  is  no  certain  method  of  distinguishing  fine 
frictions  from  rales  is,  therefore,  fully  justified. 

At  the  bases  posteriorly  one  will  frequently  find  fine  or  medium- 
sized  frictions,  which  point  to  an  old  pleurisy,  and  in  this  same  region, 
even  in  healthy  people,  on  coughing  one  can  usually  get  one  or  two 
transitory  atelectatic  or  unfolding  rales  which  are  of  no  diagnostic 
value.  Aside  from  friction  sounds,  one  can  at  times  be  misled  into 
suspecting  the  presence  of  rales  by  the  sounds  produced  by  the  act  of 
swallowing,  by  the  friction  of  hairs  under  the  stethoscope,  by  move- 
ment of  the  stethoscope  on  the  dry  skin,  and  more  especially  by  muscle 
sounds.  The  act  of  swallowing  can  produce  sounds  very  much  like 
medium-sized  moist  rales  over  the  apex,  in  front  and  behind,  and  since 
patients  will  generally  after  a  cough  swallow  unconsciously,  the  exam- 
iner must  be  on  his  guard  when,  in  auscultating  the  apex,  he  asks  the 
patient  to  cough  and  take  a  deep  breath,  for  some  patients  will  swallow 
between  the  cough  and  the  breath,  thus  producing  most  confusing  rales. 
Patients  should  be  warned  not  to  swallow  after  the  cough  when  per- 
forming this  maneuver.  Their  occurrence  and  nature  can  be  demon- 
strated very  easily  by  a  trial  on  the  patient. 

In  the  case  of  patients  with  hairy  chests  crepitations  can  be  caused 
by  frictions  of  the  stethoscope,  but  these  should  not  give  much  trouble, 
and  an  application  of  vaselin  (or  water)  will  quickly  remove  these 
frictions,  and  in  very  hairy  patients  such  an  application  should  be  a 
routine  procedure. 

In  patients  with  a  dry  skin,  for  a  similar  reason,  careless  application 
of  the  stethoscope  should  be  guarded  against,  and  here  also  vaselin  is 
useful,  but  it  should  be  noted  that  with  the  use  of  the  binaural  stetho- 
scope, which  is  almost  universal  in  this  country,  unduly  hard  application 
of  the  stethoscope  is  much  less  likely  to  occur  than  with  the  monaural. 


OBJECTIVE  SIGNS  259 

Muscle  sounds,  if  the  patient  is  in  a  proper,  restful,  easy  position 
during  the  examination,  will  not  generally  prove  troublesome,  but  in 
some  patients  in  the  suprascapular  regions  they  are  very  confusing, 
though  Walsh  thinks  tliem  more  common  in  the  infra-axillary  regions. 
They  are  caused  by  the  vibration  of  tlie  muscle  fibers  on  contraction, 
and  hence  are  oftenest  heard  on  forced  breathing,  or  in  patients  in  a 
constrained  attitude,  or  in  those  who  are  chilled  and  shiver.  Such 
sounds  continue  when  the  breath  is  held. 

Cabot  ('05)  would  distinguish  them  by  their  being  less  clear  cut, 
beginning  and  ending  less  distinctly,  and  being  less  crackling  or  bub- 
bling in  character,  as  well  as  by  their  muffled  distant  character.  He 
says  that  probably  many  rales  described  as  "  crumpling,"  "  obscure," 
"  muffled,"  "  distant,"  or  "  indeterminate "  are  in  reality  due  to  mus- 
cular contractions.  Sahli  claims  that  they  may  simulate  rough  breath- 
ing, but  this  is  doubtful. 

Turban  ('99)  dwells  especially  on  the  transmission  from  one  lung 
to  another  not  only  of  sonorous  rales  but  of  moist  rales.  The  writer 
has  often  found  such  a  transmission  in  the  back  between  the  shoulder 
blades,  but  never  in  front,  from  apex  to  apex,  as  Turban  reports.  Such 
transmission  can  be  distinguished  by  slowly  following  the  sounds  from 
one  side  to  the  other  and  noticing  the  persistence  of  timbre  and  pitch 
with  change  of  intensity. 

Vierordt  ("89)  warns  against  mistaking  bronchial  rales  transmitted 
from  the  hilus  of  the  lung  to  the  apex  for  evidence  of  apical  catarrh. 
A  little  care,  however,  in  the  examinations  can  obviate  all  these  sources 
of  error  except  in  unusual  cases,  and  with  increasing  familiarity  with 
such  work  such  difficulties  will  largely  disappear. 

Insuperable  difficulties  in  auscultation  can  be  created  by  the  presence 
of  asthma,  which,  despite  the  fact  that  there  seems  to  be  some  antago- 
nism between  the  two  processes,  is  frequently  met  with  in  tuberculosis. 
The  innumerable  sibilant  and  sonorous  rales  completely  hide  any  other 
signs,  and  one  will  have  to  wait  for  a  period  of  cessation  of  the  asth- 
matic signs  before  any  opinion  can  be  given.  Aphonia  and  hoarseness 
may  make  auscultation  of  the  voice  impossible.  Perforation  of  the 
nasal  septum  produces  a  loud,  harsh,  high-pitched  breathing  which 
makes  proper  auscultation  of  the  breath  sounds  difficult  and  useless 
unless  the  nose  is  held,  and  if  a  nasal  examination  is  neglected  it  may 
prove  puzzling.  ■        \ 

In  this  connection  it  is  to  be  noted  that  a  large  percentag  u.  '■^nts 
will  produce,  by  faulty  nasal-  or  mouth-breathing,  abnormally  .  yh 
respiratory  sounds  (see  Diagnosis),  and  tliat  in  such  cases,  which  are 
frequent  in  America,  where  nasal  obstructions  are  common,  it  is  essen- 
tial to  use  quiet   moulli-breathing  and  teach  the  patient  how  to  carry 


260  SYMPTOMATOLOGY   OF   PULMONARY  TUBERCULOSIS 

it  out  properly.  Many  patients  produce  an  excellent  imitation  of 
bronehovesicular  breathing  in  the  nose  or  larynx,  and  the  examiner 
should  bo  most  careful  to  listen  to  the  breathing  of  each  patient,  both 
during  quiet  and  deep  breathing,  and  if  necessary  teach  him  how  to 
breathe  correctly  before  proceeding  to  auscultation. 

At  one  time  great  Aveight  was  laid  on  the  value  of  a  suhdavian  sys- 
tolic murmur  in  the  early  diagnosis  of  this  disease.  It  was  first  dis- 
covered by  Stokes  ("82)  and  ascribed  by  him  to  a  falling  in  of  the 
subclavicular  region  and  consolidation.  He  noted  that  hemoptysis  or 
leeching  would  remove  it.  but  did  not  lay  any  weight  on  it  as  a  diag- 
nostic sign.  W.  Walsh  ('71)  quotes  Palmer,  who  found  it  present  in  103 
out  of  497  healthy  workmen,  and  considers  it  a  pressure  murmur  and 
so  common  in  the  healthy  as  to  be  of  no  vahie.  Euehle  ('87),  who  laid 
considerable  weight  on  it  as  an  early  diagnostic  sign,  believed  it  was 
due  to  a  kinking  of  the  artery  by  pleural  adhesions,  where  it  crossed 
the  apex  of  the  lung,  and  considered  a  systolic  subclavian  murmur, 
near  the  end  of  expiration  only,  in  the  outer  part  of  the  subclavic- 
ular fossa,  an  evidence  of  pleural  adhesions  at  the  apex.  While  it 
is  found  quite  often,  its  value  in  diagnosis  is  small,  its  freciuent 
presence  in  health  rendering  it  unrelial^le  as  a  sign  of  apical  adhe- 
sions, and  this  seems  to  be  the  consensus  of  the  more  recent  opinions 
on  the  subject. 

Accentuation  of  (he  second  pulmonic  sound  is  very  common  in  mod- 
erately advanced  or  old  cases,  and  if  much  filirosis  exists  a  pulmonary 
systolic  murmur  may  be  produced.  A  roughening  of  the  tricuspid 
systolic  sound  is  also  common.  Sokolowski  ('06)  lays  great  weight  on 
the  value  of  small  areas  of  persistent,  fine,  moist  rales  in  the  lower 
portion  of  the  lung  without  percussion  or  other  auscultatory  changes, 
as  speaking  for  small  foci  of  infection,  as  yet  too  small  to  give  other 
signs,  but  which  will  sooner  or  later  manifest  themselves.  In  these 
areas  the  breath  sounds  are  generally  unaltered,  which  makes  their  value 
doubtful,  but  it  is  not  safe  to  suppose  that  adventitious  sounds  will 
necessarily  l)e  accompanied  by  breath  changes,  as  frequently  this  will 
not  be  the  case. 

Auscultation  of  the  voice,  on  which  formerly,  through  the  influence 
of  Laennec,  much  stress  was  laid,  has  not  yielded  the  results  anticipated, 
and  modern  physical  diagnosticians  do  not  rely  on  it  to  any  great 
extent.  W.  Walsh  (*71)  has  well  stated  it  when  he  says:  "The  signs 
derived  from  modified  vocal  resonance  are  uncertain  in  character  and 
, obscii^;/in  theory,  and  though  occasionally  not  devoid  of  clinical  signi- 
fica(nce,  hold,  as  a  rule,  a  very  low  place  among  physical  aids  to  diag- 
nosis." Formerly  great  pains  were  taken  to  differentiate  bronchophony 
from  pectoriloquy,  etc.,  but  to-day  it  may  safely  be  asserted  that  the 


OBJECTIVE   SIGNS  261 

chief  thing  to  which  attention  need  !)e  given  is  the  increase  or  decrease 
of  vocal  resonance  (Flint,  '56).  The  results  of  the  determination  of  an 
increase  of  vocal  resonance  in  the  writer's  experience  agree  very  closely 
with  those  of  percussion,  and  are  of  some  value  in  verifying  the  latter, 
but  one  is  often  surprised  by  the  lack  of  correspondence,  between  vocal 
fremitus  and  vocal  resonance,  though  they  generally  roughly  correspond. 
Increased  vocal  resonance,  which  is  only  a  lessened  degree  of  bron- 
chophony (Salili)  adds  nothing  new  to  the  information  obtained  from 
bronchial  breathing  and  resonating  rales,  and  like  them  speaks  for 
consolidation  or  cavity  formation.  It  is  scarcely  necessary  to  recall 
that  the  voice  at  the  right  apex  is  normally  more  resonant  than  at  the 
left,  so  that,  equally  Avith  vocal  fremitus,  an  increase  in  this  region  must 
be  very  marked  to  have  any  meaning. 

The  whispered  voice  gives  a  better  impression  to  the  ear  than 
the  spoken,  since  this  normal  exaggeration  of  vocal  resonance  at  the 
right  apex  is  less  marked,  and  Babcock  ('OT)  considers  the  sound  clearer 
and  more  sharply  defined  in  whispering  than  in  speaking.  The  writer 
has  found  that  patches  of  increased  vocal  resonance  in  the  posterior 
bases,  just  like  areas  of  undue  heart  transmission,  give  useful  early 
warning  of  the  development  of  foci  of  trouble,  and  changes  here  are 
more  easily  determined,  since  vocal  resonance,  in  w'omen  at  least,  is 
normally  less  below  than  above.  In  the  estimation  of  vocal  resonance, 
however,  one  must  take  into  consideration  the  timbre  of  the  patient's 
voice  and  the  formation  of  his  thorax.  Men  and  deep-voiced  people, 
or  those  with  firm  chests,  have  more  vocal  resonance  than  children  and 
women,  or  those  with  weak  chests.  Once  established,  increased  vocal 
resonance  is  very  persistent  (Flint,  '56),  so  much  so  that  in  a  bilateral 
process  one  will  at  times  find  the  vocal  resonance  increased  on  the 
apparently  well  side  as  the  result  of  an  old  healed  process,  while  the 
active  trouble  is  in  the  other  side.  Decreased  vocal  resonance  is  found 
at  times  over  pleural  effusions,  thick  pleural  membranes,  emphysema, 
or  if  the  bronchus  leading  to  that  portion  of  lung  is  plugged,  but  it  is 
not  usually  of  very  great  value. 

Pectoriloquy  is  chiefly  useful  as  a  cavity  sign,  hence  is  dwelt  on 
under  the  auscultatory  signs  of  the  third  stage,  but  it  should  not  be 
forgotten  that  it  may  be  found  over  a  consolidation  if  the  consolidated 
patch  contains  a  bronchus,  and  that  whispering  pectoriloquy  should 
never  be  relied  on  too  implicitly  in  the  diagnosis  of  cavity  formation. 

Egophony,  a  tremulous,  intermittent,  bleating  voice,  was  considered 
by  Laennec  pathognomonic  of  pleuritic  effusion,  and  is  usually  found 
in  that  condition  above,  or  just  at,  the  level  of  the  fluid,  but,  like  pector- 
iloquy, it  may  at  times  be  found  over  consolidations,  but  it  is  not  com- 
mon in  tuberculosis. 


262  SYMPTOMATOLOGY   OF   PULMONARY  TUBERCULOSIS 

When  a  patient  is  aphonic,  or  hoarse,  Sehrwald's  plegaphonia  (An- 
ders, H.,  '07),  or  artificial  vocal  resonance,  is  of  use  if  it  is  important 
to  test  the  vocal  resonance.  The  thyroid  cartilage  is  lightly  percussed 
by  the  hammer,  using  a  pleximeter,  with  the  patient's  mouth  closed, 
and  the  resultant  pulmonary  sounds  are  auscultated. 

Aufrccht  ('05)  speaks  of  what  he  calls  a  "bronchial  after-sound" 
(hronchialer  Nachhauch)  in  cases  of  infiltrated  lung  and  pneumonia. 
It  is  a  rough  bronchial  after-sound  heard  at  the  end  of  the  spoken  word, 
or  after  it,  which  corresponds  to  the  expiratory  bronchial  breath.  He 
claims  to  have  been  the  first  to  note  it,  but  Flint  referred  to  the  same 
thing  as  a  bronchial  souffle,  accompanying  the  spoken  word,  and  quotes 
a  case  in  point. 

Enlarged  broiicliial  glands  are  most  apt  to  l)e  found  in  the  second 
stage,  though  the  fluoroscope  will  at  times  reveal  them  in  incipient 
cases.  The  most  typical  auscultatory  sign  of  such  enlarged  glands  is 
a  sibilant  inspiration  heard  on  one  side,  or  less  often  on  both  sides,  of  the 
sternum,  at  the  level  of  the  second  or  third  ribs,  and  it  is  transmitted 
downward  and  outward.  Less  commonly  it  will  be  heard  behind  be- 
tween the  scapuljfi  and  the  spinal  column.  This  is  most  suggestive,  if 
not  diagnostic.  It  is  due  to  a  compression  of  one  or  both  main  bronchi 
by  the  glands.  Barety  ('74)  considered  a  blowing  bronchial  expiration, 
commonest  behind,  as  very  typical.  Barthez  and  Eilliet  ('61)  noted 
as  diagnostic  a  large,  noisy  ronchus,  masking  the  respiratory  sound, 
transmitted  to  a  distance,  very  persistent,  unlike  a  sibilant  rale  of 
bronchitis,  and  due,  they  believed,  to  tracheal  com])ression. 

Emphysema,  if  in  scattered  foci  due  to  phthisis,  is  difficult  to  rec- 
ognize, but  if  limited  to  an  apex  around  a  focus  of  trouble  the  typical 
prolonged  feeble  expiration  will  often  serve  to  enlighten  one.  When 
general,  it  has  antedated  the  tuberculosis,  and  gives  all  the  signs  on 
inspection,  palpation,  and  percussion,  which  make  it  unmistakable,  but 
in  such  a  case  it  can  render  the  auscultation  of  the  tuberculous  lesions 
much  more  dilficult. 

In  all  stages  of  pulmonary  tuberculosis,  but  especially  in  the  second 
stage,  it  is  needful  to  remember  that  there  always  exists  in  the  lungs 
much  more  trouble  than  the  most  acute  diagnostician  can  discover,  and 
that  what  is  found  are  only  the  more  sviperficial  or  advanced  lesions, 
while,  as  innumerable  autopsies  have  shown,  there  is  always  an  advancing 
border  of  trouble  which  stretches  well  beyond  the  extreme  limit  deter- 
minable by  physical  diagnosis. 

While  the  general  tendency  of  tuberculosis  is  toward  a  gradual 
spread  of  the  disease,  a  few  cases  which,  while  not  advancing  toward  a 
cure,  will  remain  stationary  for  long  periods,  the  signs  not  changing 
materially,  and  while  of  course  one  would  prefer  to  see  a  gradual  retro- 


OBJECTIVE   SIGNS  263 

gression,  \yith  clearing  up  of  the  involved  areas,  such  cases  are  often 
very  favorable  and  speak  for  the  development  of  fibrosis. 

When  a  case  is  advancing  toward  cure,  there  is  noted  first  a  diminu- 
tion in  the  number,  size,  and  quality  of  the  rales,  abundant  rales  becom- 
ing scanty,  large  rales  becoming  small,  and  moist  rales  becoming  dry. 
With  this  there  occurs  a  lessening  in  the  intensity  of  the  breath  sounds 
which  retrograde  in  somewhat  the  same  order  in  which  they  have  ad- 
vanced,  though  where  there  has  been  any  but  the  slightest  trouble, 
normal,  pure,  vesicular  breathing  never  entirely  returns,  although  the 
impure  breathing  may  be  masked  greatly  by  the  development  of  com- 
pensatory emphysema.  While  in  the  most  favorable  cases  rales  dis- 
appear entirely,  this  is  not  always  the  case,  and  the  writer  has  seen 
patients  Avho  have  been  well  for  years  in  whom  he  could  demonstrate 
small  patches  of  fine  rales,  generally  dry,  though  they  sometimes  seemed 
moist,  and  these  are  probably  pleural  and  not  parenchymatous. 

Auscultation  of  the  Third  Stage. — The  use  of  the  term  stage 
of  cavitation  for  the  third  or  most  advanced  stooge  of  tuberculosis,  has 
often  been  objected  to  on  the  ground  that  cavities  exist  at  a  much  earlier 
period,  as  shown  by  the  fact,  demonstrated  by  Sokolowski,  that  elastic 
tissue  can  be  found  in  the  sputum  within  a  few  weeks  of  the  discovery 
of  early  signs;  but  while  this  is  ti-ue,  and  on  anatomic  and  pathologic 
grounds  the  term  is  not  correct,  clinically  and  in  the  study  of  the  phys- 
ical signs  it  corresponds  very  closely  with  the  facts,  and  this  stage  is 
especially  characterized  by  the  signs  and  symjjtoms  of  cavitation  which 
generally  dominate  the  clinical  picture,  though,  as  Fox  notes,  signs  of 
extensive  solidification  and  of  fibrosis  are  also  prominent.  Cabot  ('05) 
considers  these  latter  the  most  prominent. 

Just  as  the  first  stage  is  marked  by  slight  changes  in  the  inspiratory 
and  expiratory  murmurs  and  fine  dry  rales,  the  second  by  broncho- 
vesicular  and  bronchial  breathing  and  medium  and  fine  moist  rales,  so 
this  stage  is  characterized  by  tubular  and  cavernous  breathing  with 
metallic  overtone  (Leube,  '91)  and  large,  moist  rales  and  gurgles  with 
resonating  character.  At  the  same  time  it  should  be  noted  that,  on 
account  of  the  multiplicity  of  lesions,  the  signs  of  the  third  stage  are 
usually  extremely  varied,  which  makes  its  auscultation  often  most  un- 
satisfactory and  confusing,  as  can  well  be  understood  when  one  exam- 
ines the  lungs  of  such  a  case  at  the  autopsy.  Thus  it  is  much  more 
difficult  in  the  tliird  stage  to  draw  correct  conclusions  as  to  the  exact 
existing  physical  conditions  in  the  lungs  than  in  the  other  stages. 

As  the  process  so  generally  begins  in  the  apical  regions  and  advances 
downward,  the  third  stage  generally  shows  the  signs  of  all  the  stages, 
advanced  cavity  fornuition  above,  consolidation  with  softening  in  the 
middle  and  disseminated  tubercles  below,  so  that,  as  a  general  rule,  the 


264  SYMPTOMATOLOGY   OF    PULMONARY  TUBERCULOSIS 

signs  of  the  third  stage  are  found  ahove  the  fourtli  I'ih,  and  cavities 
will  not  be  discoverable  in  the  base  except  in  very  old  chronic  cases  of 
long  duration. 

When  it  is  recalled  how  many  conditions  must  be  satisfied  before  a 
cavity  can  be  demonstrated — superficial  location,  considerable  size,  no 
cavity  less  than  a  walnut  heing  discoverable  (Gerhardt,  'l)U),  connection 
with  the  air,  more  air  than  secretion  in  its  contents,  etc. — and  that 
there  is  no  single  sign  which  can  be  considered  pathognomonic,  it  is  not 
remarkable  that  autopsies  show  such  a  large  number  of  cavities  which 
were  overlooked  during  life.  Landis  (*06),  in  an  excellent  study  of 
76  cavities  in  515  cases  in  the  Phipps  Institute,  of  Philadelphia, 
Avhieh  had  been  carefully  observed  by  the  staff,  found  that  58  had  been 
recognized  and  LS  overlooked,  a  better  percentage  of  diagnosis  than 
would  usually  be  obtained.  Fortunately,  the  determination  of  the  pres- 
ence of  a  cavity,  while  important,  has  not  the  extreme  importance  once 
attached  to  it,  for,  as  Sokolowski  says  (*0()),  the  presence  of  excavation, 
whose  recognition  is  important,  can  be  sooner  and  more  surely  deter- 
mined by  the  discovery  of  elastic  filjers  in  the  sputum,  though  of  course 
this  gives  no  iriformation  as  to  its  location.  jMoreover,  the  diagnosis 
in  this  stage  never  depends  on  the  physical  signs,  and  examination  is 
apt  to  be  of  more  importance  from  a  prognostic  than  a  diagnostic 
standpoint. 

Broncliial  or  {uhiihir  hrrafliinf/,  as  has  been  noted,  appears  in  the 
second  stage,  with  tlie  occurrence  of  appreciable  amounts  of  consoli- 
dation, and  so  in  itself  cannot  be  considered  a  characteristic  of  the 
third  stage.  It  is,  however,  very  commonly  found,  since  areas  of  con- 
solidation are  always  present,  and  Loomis  ('77)  taught  that  in  ad- 
vanced tuberculosis  a  cavity  could  be  suspected  if  there  was  found 
intense  bronchial  breathing,  localized,  and  accompanied  by  metallic 
moist  rales.  The  typical  respiration  of  the  third  stage  is  cavernous  or 
more  rarely  amphoric.  Most  of  the  German  writers  following  Skoda 
('64)  admit  no  distinction  betAveen  bronchial,  cavernous,  and  amphoric 
breathing,  Leube  ("91)  considering  the  latter  to  be  a  bronchial  breath- 
ing with  a  metallic  tone,  but  Sahli  treats  of  them  as  distinct  subvarie- 
ties,  and  the  majority  of  American,  English,  and  French  authors  recog- 
nize their  distinction  as  independent  types  as  valid,  and  it  seems  that 
either  as  a  subvaricty  or  as  an  independent  type  the  division  should  be 
recognized  as  justifiable  and  useful.  Such  a  difference  of  opinion,  how- 
ever, shows  that  there  is  need  of  great  care  in  distinguishing  them. 

Cavernous  breathing  has  a  low-pitched,  blowing  inspiration,  bron- 
chial breathing  a  high-pitched  one;  in  cavernous  breathing  the  expira- 
tion is  even  lower  pitched,  in  bronchial  breathing  higher  pitched;  cav- 
ernous respiration  is  weak  and  hollow,  bronchial  breathing  intense  and 


OBJECTIVE   SIGNS  265 

tubular.  When  there  is  a  combination  of  solidification  and  cavita- 
tion there  may  be  a  mixture  of  both,  which  Flint  ('T5)  distinguishes 
as  bronchocavernous.  Cavernous  breathing  Ij}'  itself,  if  not  well  limited, 
cannot  be  relied  on  to  any  great  extent,  and  of  it,  as  of  so  many  other 
of  the  signs  of  tuberculosis,  it  may  be  said  that  it  is  chiefly  of  value 
if  circumscribed,  combined  with  other  symptoms,  and  surrounded  by 
an  area  of  bronchial  breathing,  just  as  the  percussion  sign  of  cracked- 
pot  resonance,  to  be  valuable,  must  be  sharply  defined  and  surrounded 
by  an  area  of  dullness.  Of  course,  if  to  this  are  added  large  moist  rales 
or  a  metallic  tinkle  or  metamorphosing  breathing,  etc.,  tlie  certainty 
is  increased,  but  such  happy  combinations  of  convincing  signs  are  the 
exception  rather  than  the  rule,  it  being  much  easier  to  put  together 
a  table  of  such  typical  signs  for  a  text-book  than  to  find  them  com- 
bined in  a  patient,  and  in  Landis's  cases  29  showed  cavernous  ])reath- 
ing,  19  amphoric,  and  13  bronchial. 

Amphoric  hreatliing  is  so  well  imitated  by  blowing  across  the  mouth 
of  an  empty  bottle  that  anybody  can  produce  for  himself  a  perfect 
reproduction  of  it.  It  is  metallic  and  blowing,  and  is  almost  unmis- 
takable, but  for  its  production  there  is  needed  a  cavity  of  at  least  4  to 
6  cm.  diameter  (A.  Fraenkel,  '91),  with  smooth,  stiff  walls  and  a  con- 
sideral)le  bronchus  entering  it,  hence  it  will  not  be  a  common  finding, 
but,  if  pneumothorax  can  be  excluded,  generally  not  difficult  of  diag- 
nosis, it  is  a  positive  sign  of  great  value. 

Metamorphosing  breathing,  in  which  the  first  part  of  the  inspira- 
tion is  high-pitched  and  resonant,  and  which  changes  during  the. larger 
part  of  inspiration  to  bronchial  or  vesicular  hreatliing,  is  variously 
explained  as  due  to  partial  occlusion  of  the  bronchus  leading  to  the 
cavity  by  mucus  which  the  latter  part  of  insjjiration  is  strong  enough 
to  remove,  or  to  the  increasing  dilatation  of  the  cavity  and  its  opening, 
which  changes  its  note,  or  to  the  entry  of  air  into  unequally  diseased 
areas  (Sahli,  '02).  This  is  a  fairly  sure  sign,  but  is  too  rare  to  be  of 
great  assistance. 

Large  moist  rales  are  the  typical  nlle  of  this  stage,  and  speak  either 
for  rapidly  advancing  softening  or  cavity.  In  the  apex,  where  there 
are  no  laige  l)ronclii,  they  are  a  very  valuable  cavity  sign,  Vierordt,  as 
already  noted,  considering  them  the  most  typical  sign  of  excavation 
in  an  apex.  Lower  down  they  can  be  produced  in  the  large  bronchi, 
and  are  therefore  not  as  diagnostic,  nor  are  they  as  common.  When 
they  increase  in  numljer  and  size  they  become  gurgles,  which  are  very 
numerous  and  very  large  bnljbling  sounds,  masking  everything  else, 
and  which,  on  the  whole,  are  the  most  certain  sign  of  advanced  and 
extensive  excavation,  Stokes  ('82)  hinging  the  diagnosis  of  cavity  on 
cavernous  l)reatliing  and  gurgles.  Unfortunately,  they  are  usually  found 
19 


266    SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

only  in  hopelessly  advanced  cases  where  diagnosis  and  prognosis  have 
been  long  since  settled. 

In  the  majority  of  cavities  we  find  fairly  numerous  moist  rales, 
with  various  indeterminate  crackling,  crumpling  sounds,  and  in  the 
surrounding  tissue  medium  and  fine  moist  or  dry  rales,  which  increase 
with  the  progress  of  the  disease,  but  which,  when  the  case  improves, 
gradually  lessen  and  disappear,  the  cavity  being  said  to  become  "  dry  " 
and  only  presenting  breath  and  voice  changes.  Naturally,  such  "  dry- 
ing "  of  a  cavity  is  a  prognostic  sign  of  great  value  and  good  omen. 
By  degrees  the  fibroid  shrinking  of  the  surrounding  lung  begins,  and 
the  signs  become  less  evident,  until  very  often  no  signs  remain,  which 
in  a  new  case  would  lead  to  a  suspicion  of  a  cavity.  Such  dry  cavities 
luay  persist  for  years,  rarely  remaining  truly  dry,  but  producing  gen- 
erally a  small  but  constant  amount  of  mucopurulent  sputum,  even  when 
all  signs  of  moisture  are  absent.  If  the  victim  of  such  a  cavity  leads 
a  healthy  country  life  in  a  clean,  dust-free  air,  it  will  generally  remain 
inactive,  but  a  return  to  the  dust  of  cities,  or  much  railroad  traveling, 
will  often  reinfect  them  with  pus  organisms  and  cause  a  return  of  active 
ulceration  and  moisture. 

It  is  such  cavities  as  these  also  which  in  old  inactive  fibroid  cases 
may  cause  sudden,  and  at  times  fatal,  hemorrhages  in  apparently  cured 
cases,  or,  if  it  does  not  go  as  far  as  this,  they  account  for  the  recur- 
rence at  intervals  of  pink  sputum,  which  will  often  follow  overexertion 
or  colds.  The  writer  recalls  such  a  case  in  which  the  cavity  had  been 
dry  and  contracted  for  two  years,  and  the  patient  had  returned  to  work 
in  good  health,  when  suddenly,  probably  from  a  small  miliary  aneurysm 
in  the  wall  of  the  cavity,  hemorrhage  occurred  with  a  fatal  termination. 

While,  as  a  usual  thing,  the  cavities,  for  the  reasons  stated  earlier,  are 
found  above  the  third  or  fourth  rib,  one  can,  at  times,  through  the  coales- 
cence of  several  cavities,  see  a  whole  lobe  or  more  rarely  a  whole  lung 
converted  into  a  large  sac,  and  a  beautiful  example  of  the  latter  condition 
is  to  be  seen  in  the  pathologic  collection  of  the  Phipps  Institute  at  Phila- 
delphia. 

Metallic  tinl-Je  is  a  rare  sign.  It  is  not  caused,  as  was  once  thought, 
by  the  dropping  of  secretion  from  the  wall  of  a  cavity  into  its  fluid  con- 
tents, but  by  the  bursting  of  bubbles  of  air  at  the  surface  of  the  fluid 
in  a  cavity  with  whose  note  they  are  consonant.  It  is  only  found  in 
pneumothorax  and  large  cavities,  and  when  found  is  a  positive  sign  of 
one  of  these  conditions.  The  Germans,  who,  as  noted,  do  not  distinguish 
cavernous  or  amphoric  breathing,  consider  a  metallic  tone  to  bronchial 
breathing,  moist  sounds,  or  rales  one  of  the  best  cavity  signs  (Gerhardt), 


OBJECTIVE   SIGNS  267 

this  being  ])iit  another  wa}'  of  recognizing  the  Vakie  of  what  in  France, 
England,  and  America  is  called  cavernous  breathing. 

The  vocal  resonance  of  the  third  stage  may  be  varied,  but,  as  a 
rule,  it  is  strongly  exaggerated.  Over  consolidation  one  can  get  either 
bronchophony,  pectoriloqu}^,  or  amphoric  voice.  Laennec  considered 
pectoriloquy  pathognomonic  of  cavity,  but  it  can  be  heard  over  a  con- 
solidated lung  if  a  large  bronchus  passes  through  the  consolidation. 
It  demands  a  large  cavity  with  firm  Avails,  freely  communicating  with 
the  bronchus,  nearly  empty,  and  superficially  located.  Such  conditions, 
of  course,  assure  its  infrequence.  Even  whispering  pectoriloquy,  while 
a  more  relialjle  sign,  can  be  found  over  solid  lung,  and  W.  Walsh,  who 
is  su])posed  to  be  sponsor  for  this  sign  of  cavity,  says  ('71):  "Vocal 
resonance  should  never  be  seriously  appealed  to  in  diagnosis  of  a  cavity. 
The  form  of  resonance  most  nearly  distinctive  of  an  excavation  is 
whispering  pectoriloquy;  but  cavities  may  exist  without  this,  while 
resonance  of  the  sort  ma}'  exist  under  physical  conditions  directly 
the  reverse  of  excavation."  And  again :  "  Where  the  quality  of  the 
resonance  is  markedly  hollow  and  ringing,  and  where  it  exists  in  the 
whis])ering  forms,  I  long  believed  that  it  strongly  indicated  a  cavity; 
l)ut  I  have  found  whispered  pectoriloquy  over  even  simple  acute  hepati- 
zation, as  well  as  in  the  retraction  period  of  pleurisy." 

Landis  ('06),  who  found  it  in  a  majority  of  cases  and  believes  it 
a  valual)le  sign,  does  not  consider  it  pathognomonic  and  found  it  over 
consolidation  al)Out  a  bronchus.    It  should  not  be  relied  on  too  implicitly. 

Whispering  pcctoriloqny  over  a  cavity  differs  from  that  over  solidi- 
fication just  as  cavernous  breathing  differs  from  bronchial — i.  e.,  it  is 
low  and  blowing  instead  of  high-pitched  and  tubular.  Once  more  it 
can  be  said  that  localized,  and  accompanied  by  other  signs,  its  value 
is  considerable,  or  to  quote  Stokes  ('82)  :  "Taken  alone  it  is  absolutely 
without  value,  but  when  in  combination  with  other  signs  it  strengthens 
the  diagnosis." 

Amphoric  voice,  a  cavernous  voice  with  amphoric  echo,  demands  a 
very  large,  thin,  smooth-walled  cavity,  and  is  most  typically  heard  in 
pneumothorax,  and,  like  amphoric  breathing,  if  pneumothorax  can  be 
excluded  it  is  a  positive  sign. 

To  recapitulate,  the  most  reliable  auscultatory  signs  of  pulmonary 
excavation  are  cavernous  breathing,  large  most  rales  or  gurgles,  and 
whispering  pectoriloquy,  but  the  filling  of  the  cavity  with  pus,  the 
occlusion'of  its  outlet,  or  its  location  in  the  middle  of  healthy  lung  tis- 
sue, may  render  its  diagnosis  impossible.  While  cases  which  have  ad- 
vanced to  the -third  stage,  with  demonstrable  cavitation,  have  a  poor 
outlook  for  recovery,  a  small  number,  as  autopsies  have  abundantly 
proved,  may  become  arrested  if  the  process  is  not  too  active  and  the 


268  SYMPTOMATOLOGY   OF   PULMONARY  TUBERCULOSIS 

resisting  powers  sufficient,  so  that  the  system  can  form  fibroid  tissue 
around  the  lesions. 

In  such  cases  the  symptoms  of  ulceration  by  degrees  lessen,  expecto- 
ration becomes  less  and  less  purulent  and  more  mucoid,  rides  decrease 
and  finally  disappear,  symptoms  lessen  coincidently  with  an  increase  of 
general  vitality  and  strength,  and  the  jiatient  can  reach  quite  a  fair 
state  of  health  and  Avorking  efficiency.  Such  cases  are,  however,  the 
exception,  and  may  at  any  time,  without  any  imprudence  on  the  ])art 
of  the  patient,  relapse;  the  dormant  disease  becomes  active,  or  sudden 
hemorrhages  occur. 

Thus  if  one  would  obtain  permanent  and  satisfactory  results,  it  is 
essential  to  discover  and  diagnose  cases  of  tuberculosis  at  a  time  Avhen 
the  lesion  is  so  limited  and  so  little  destruction  of  tissue  has  occurred 
that  the  body  may  be  able  to  encapsulate  the  process,  which  is,  of  course, 
impossible  Avhon  the  disease  has  reached  this  stage. 

Roentgen  Rays. — The  discovery  of  the  X-ray  and  its  application  to 
internal  medicine  has  placed  at  the  disposal  of  physicians  a  method  of 
physical  diagnosis  which  has  proved  to  be  of  great  value,  especially  in 
pulmonarv  diseases.  It  has  now  l)cen  used  long  enough  to  justify  con- 
clusions as  to  its  utility  and  its  limitations  in  this  branch  of  medical 
work,  and  though,  as  was  to  be  expected,  excessive  claims  have  been 
made  for  it  ])y  some  enthusiasts,  tlie  majority  of  physicians,  including 
many  prominent  radiologists,  recognize  tliat,  however  great  its  value,  it 
is  to  be  looked  on  ratber  as  an  addition  to  than  as  a  substitute  for  the 
standard  methods  of  examination. 

After  having  used  the  Eoentgen  ray  fluorosco])ically  in  all  his  exam- 
inations for  the  past  seven  years,  tlie  writer  believes  tbat  in  the  majority 
of  cases  an  expert  physical  diagnostician  will  be  able  to  make  a  diagnosis 
of  incipient  tuberculosis  sooner  than  will  the  radiologist,  but  in  a  few 
cases  the  latter  will  discover  small  foci  of  trouble  in"  the  lung  which 
neither  auscultation  nor  percussion  would  reveal.  There  are  certain 
pulmonary  conditions,  especially  enlargements  of  the  tracheobronchial 
glands  and  peribronchial  infdtrations,  which  can  be  diagnosed  far  earlier 
and  better  by  this  method  than  l)y  any  other. 

Despite  its  limitations,  therefore,  exploration  by  Eoentgen  rays  is  a 
most  valuable  addition  to  our  means  of  examination,  if  used  in  conjunc- 
tion with  the  standard  methods.  Of  the  two  ways  of  using  the  Eoentgen 
ray,  fluoroscopy,  or  the  production  of  a  shadow  picture  on  a  fluorescent 
screen,  and  radiography,  or  the  record  of  the  picture  on  a  photographic 
plate,  the  latter  gives  more  complete  details,  and  by  it  expert  radiologists 
can  now  demonstrate  the  existence  of  pulmonary  tuberculosis  in  certain 
cases  at  an  extremely  early  stage.  L.  G.  Cole,  of  'New  York,  has  been 
able  to  demonstrate  small  foci  in  an  apex,  and  more  especially  along 


OBJECTIVE   SIGNS 


269 


the  branches  of  the  bronchial  tree,  and  to  prove  their  existence  after- 
wards at  antopsy,  when  they  were  of  such  a  size  as  to  be  entirely  undis- 
coverable  by  the  most  acute  diagnosticians. 

While,  however,  the  radiograph  can  at  times  recognize  lesions  undis- 
coverable  by  the  fluoroscope,  the  difficulty  is  that  the  expert  physical 
diagnostician  is  rarely  an  expert  radiologist,  or  vice  versa.  Moreover, 
the  apparatus  for  radiography  is  so  complex,  the  technic  so  elaborate. 


Fig.  5fj. — Postekior  View  of  the  Lungs  in  an  Acute  Active  Case,  Showing 
Multiple  Cavities  (K)  in  the  Infiltrated  Upper  Left  Lobe.  In  the  right 
lung  is  infiltration  (G")  starting  from  around  the  roots  of  the  bronchi,  a  fa\orite 
spot,  and  in  this  region  a  calcified  bronchial  gland  can  be  seen  (/).  The  right 
ventricle  of  the  heart  is  enlarged. 

the  time  required  so  great,  and  the  proper  development  and  interpreta- 
tion of  the  plates  a  matter  of  such  special  skill,  that  its  use  will  neces- 
sarily remain  confined  to  specialists,  to  wliom  tlie  patient  will  be  sent  by 
his  physician  for  study  and  report. 

On  the  other  hand,  fluoroscopy,  while  in  certain  cases  not  giving  as 


270    SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

early  information  as  radiography,,  gives  immediate  information  of  great 
value,  is  much  less  time-consuming,  the  apparatus  and  technic  is  much 


Fig.  57.— Anterior  View  of  an  Old  Chronic  Process  with  Intense  Consolida- 
tion IN  the  Upper  Left  Lung  (H)  and  a  More  Extensive  but  Less  Dense 
Infiltration  in  the  Right  Side  ((?),  and  with  Peribronchial  Enlarge- 
ments Along  the  Course  of  the  Bronchial  Tree  on  the  Right  in  its 
Downward  Course.  Note  also  the  area  of  infiltration  (G)  advancing  in  front 
of  the  consolidation  of  the  upper  left  lobe.  In  the  right  lung  are  to  be  seen 
two  cavities  (A'),  possibly  bronchiectatic  (surrounding  lung  relatively  clear 
instead  of  infiltrated,  as  usual,  around  a  cavity).  The  bronchial  glands  on  the 
right  are  enlarged  at  the  root  and  along  the  bronchi,  and  where  they  cross  the 
ribs  (L)  the  summation  of  the  two  shadows  make  denser  spots.  The  heart  is 
drawn  slightly  to  the  right,  which  would  suggest  the  existence  of  fibroid  con- 
traction in  the  right  side. 

less  complex  and  expensive,  and  the  interpretation  of  the  findings  very 
much  simpler,  so  that  the  physical  diagnostician  can  easily  adopt  it  in 
the  routine  examination  of  his  cases  without  loss  of  time.     Moreover,  it 


OBJECTIVE   SIGNS  271 

not  only  gives  liim  assistance  in  making  an  early  diagnosis,  but  it  will 
inform  him  of  the  topography  of  the  disease  and  can  visualize  to  him, 
as  can  no  other  procedure,  the  condition  of  the  lung.  The  advance  and 
retrogression  of  the  disease  thus  becomes  actually  observable.  While  the 
radiograph  gives  such  fullness  of  detail  that  it  is  difficult,  even  for  an 
expert,  to  distinguish  at  times  between  normal  and  pathologic  shadows, 
the  picture  given  by  the  fluoroscope  shows  none  of  those  misleading  nor- 
mal shadows,  and  thus  is  much  easier  to  interpret.  Correct  information 
as  to  alterations  in  motion  can  only  be  obtained  by  it,  and,  except  for 
the  detection  of  deeply  seated  small  foci  of  a  half  inch  or  less  in  diam- 
eter, fluoroscopy  is  most  satisfactory.  Holzknecht  says  that  in  chest 
examinations  radioscopy  must  be  the  method  chiefly  used,  and  F.  Kraus, 
one  of  the  best-known  diagnosticians  and  clinicians,  holds  similar  views. 

The  writer  believes  that  the  use  of  radiography  will  be  confined  to 
the  X-ray  specialist,  and  that  the  physician,  through  want  of  time,  will 
most  advantageously  use  the  fluoroscope.  It  is  hoped  that  fluoroscopy 
will  be  more  generally  adopted  by  the  profession  for  pulmonary  cases. 

Before  proceeding  to  a  description  of  the  changes  found  in  the  lungs 
by  means  of  flouroscopy,  it  need  hardly  be  noted  that  it  is  essential  that 
the  physician  be  entirely  familiar  with  the  normal  fluoroscopic  picture 
if  he  is  not  to  be  misled  by  certain  appearances  which  might  at  first 
seem  to  him  pathologic.  The  normal  lungs,  from  in  front,  are  seen  on 
the  fluoroscopic  screen  as  two  irregular,  triangular  areas  of  mildly  glow- 
ing translucence,  separated  by  a  more  or  less  triangular,  vertical,  dark 
shadow,  with  its  broad  base  below,  which  is  produced  by  the  sternum, 
mediastinum,  spinal  column,  heart,  and  aorta  (Fig.  60).  The  sternum 
makes  a  vertical,  bandlike,  dark  shadow,  extending  from  the  diaphragm 
upward  to  between  the  shadows  of  tlie  clavicles,  and  this  central  shadow 
is  enlarged  to  the  left  from  the  second  ril)  to  the  diaphragm  by  the  shadow 
of  the  aorta,  pulmonary  artery,  auricle,  and  ventricle  (Fig.  64).  This 
enlargement  to  the  left  consists  of  three  scallops,  the  smaller,  above,  being 
that  of  the  aortic  arch  (Fig.  60),  the  medium  that  of  the  pulmonary 
artery  and  auricle,  the  largest,  below,  that  of  the  ventricle  (Fig.  60).  On 
the  right  side,  extending  from  the  fifth  rib  to  the  diaphragm,  is  a  narrow, 
paler,  triangular  shadow,  cast  by  the  right  ventricle  (Fig.  60). 

The  translucence  of  the  lung  area  increases  from  above  downward, 
being  quite  faint  above  the  clavicles  and  quite  bright  at  the  bases  (Fig. 
60),  and  brightening  considerably  on  deep  inspiration,  wliich  also  in- 
creases the  clearness  of  the  cardiac  and  diaphragmatic  outlines.  Across 
this  bright  area  run  the  shadows  of  the  clavicle  and  the  ribs,  and  in 
favorable  cases  we  also  see  through  the  intervening  lung  the  posterior 
portion  of  the  ribs,  the  superposition  of  the  two  producing  a  latticelike 
shadow  effect  (Fig.  57).     Above  the  clavicle  the  apex  rises  in  a  dome 


272     SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

(Fig.  59),  the  apices  being  normally  of  equal  heiglit  and  slightly  shaded 
by  being  covered,  on  their  posterior  surfaces,  by  ribs  and  thick  muscles. 
The  inner  border  of  the  lung  area  is  quite  sharply  marked  off  from  the 
sternum  and  heart  (Fig.  6U).  The  outer  border  is  rather  indistinct  and 
ill-defined,  while  the  lowei'  border  is  the  most  distinct  of  all,  standing 
out  sharply  in  contrast  Avith  the  blackness  of  the  diaphragm  and  abdo- 
men. This  lower  border  curves  sharply  downward  at  its  outer  end  to 
form  one  side  of  the  costodiaphragmatic  angle  (Fig.  G"*;?),  and  is  short- 
ened at  its  inner  extremity  by  the  projection  of  the  heart,  the  lower 
border  of  whose  apex  makes  an  angle  with  it.  In  a  certain  number  of 
patients  the  air  in  the  stomach  makes  a  bright  area  below  the  diaphragm, 
this  muscle  being  seen  in  profile  as  a  thin  dark  arch,  movable  on  respi- 
ration and  separating  this  area  from  that  of  the  lung.  In  thin  subjects 
with  heavy  bones  one  can  at  times  see  the  shadow  of  the  angle  and  lower 
portion  of  the  scapula  (Fig.  62),  showing  through  the  chest  from  behind 
and  closely  simulating  an  area  of  shadow  in  the  lower  and  lateral  por- 
tions of  the  lungs.  In  the  same  way,  in  women  the  breast  may  produce 
deceptive  shadows  (Figs.  60  and  61),  especially  in  the  posterior  view, 
but  movement  of  the  scapula  or  Ijreast  will  easily  dispel  doubt. 

The  heart  shadow  is  (juite  clear-cut  and  dark,  though  not  so  dark 
as  the  sternum,  but  is  lighter  in  its  auricular  and  aortic  portions,  and 
its  motion  can  be  w'ell  seen,  especially  on  deep  inspiration.  The  motion 
of  the  bases  should  be  even  on  both  sides,  but  the  difference  between 
extreme  inspiration  and  ex])iPation  is  slightly  greater  on  the  left  side 
than  on  the  right,  owing  to  the  presence  of  the  liver  on  the  right  side. 
It  must  be  recalled  that  for  the  same  reason  the  arch  of  the  diaphragm 
is  a  little  higher  (^  to  f  of  an  inch)  on  the  right  side  than  on  the  left 
(Fig.  56),  and  that  this  must  not  be  mistaken  for  that  pathologic  eleva- 
tion produced  by  shrinkage  of  the  overlying  lung  (Figs.  59  and  60). 

In  successful  fluoroscopic  examinations  there  is  seen  on  each  side  of 
the  sternum,  from  the  level  of  the  second  rib  down  to  the  fifth,  a  faint 
ribbonlike  shadow  (Figs.  59-62),  radiating  dow^nward  and  slightly  out- 
ward from  the  border  of  the  sternum,  and  formed  by  the  hilus  of  the 
lung,  bronchi,  and  blood-vessels,  and  called  the  accompanying  shadow 
of  the  h.eart.  On  a  radiograph  the  same  shadow  is  much  more  pro- 
nounced. The  lung  markings,  indistinct  branching  or  marbled  shadows 
all  over  the  lung,  seen  in  good  radiographs  of  the  normal  lung  (Fig. 
61,  A),  are  not  seen  on  the  Huoroscope  at  all,  thus  removing  a  fruitful 
cause  of  doubt.  Seen  from  behind,  the  lung  area  is  still  of  about  the 
same  shape,  but  the  outer  half  of  the  area  is  rendered  indistinct  by  the 
shadow  of  the  scapula,  especially  by  its  spine,  inner  border,  and  angle, 
in  that  order  of  importance.  The  shadow  of  the  inner  border  may  re- 
semble an  accompanying  shadow,  but  motion  of  the  shoulder  blade  will 


OBJECTIVE   SIGNS 


273 


quickly  remove  any  doubt.  From  behind,  the  heart  shadow  is  large  and 
less  distinct,  being  farther  from  the  screen,  and  the  right  ventricle  shows 
up  more  plainly  to  the  right  of  the  spinal  column  than  it  does  in  front. 
The  accompanying  shadows  are  not  seen  from  behind  in  the  normal  lung. 
In  thin  subjects  the  clavicle  is  clearly  seen  through  the  intervening 
lung,  dividing  the  apex  from  the  rest  of  the  lung.  Naturally,  the  fluo- 
roscopic picture  is  clearest  in  thin  people  and  children,  while  in  very 


Fig.  58. — Axtekior  View  of  an  Extensively  Involved  Left  Lung.  A  cavity 
is  seen  in  the  upper  left  lobe  (K)  with  infiltration  (G)  between  it  and  the  dense 
consolidation  lower  down  (//).  This  consolidation  is  located  outside  and 
slightly  above  the  heart,  a  favorite  ^ite  for  it  (see  text  as  also  under  Percussion). 
On  the  ri^ht  is  seen  glandular  enlargement  and  thickening  around  the  root 
of  the  lung  (F).  The  right  border  of  the  heart  at  B,  despite  the  left-sided 
trouble,  is  not  yet  dislocated  to  the  left. 

fat  or  very  large  muscular  people  fluoroscopy  and  radiography  are  both 
relatively  valueless,  owing  to  the  lack  of  definition  of  the  image,  which 
no  increase  of  intensity  of  the  light  can  overcome.  In  this  connection 
it  is  to  be  noted  that  the  lung  should  not  be  examined  with  tubes  of 
very  high  vacuum  and  great  penetration,  as  Ihey  obliterate  faint  shadows 
and  render  the  ])icture  indistinct  and  unsatisfactory,  and  that  one  should 
work  with  a  tube  of  llie  lowest  vacuum  that  will  give  a  clear  picture, 
just  as  with  the  microscope,  in  the  study  of  details,  little  light  is  used, 
details  being  obscured  by  too  brilliant  illumination. 


274    SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

The  i:>ictnre  given  by  the  lung  in  puhnonary  tuberculosis  may  be 
varied;  on  the  one  hand,  with  definite  and  serious  auscultatory  signs 
one  will,  in  acute  miliary  cases,  usually  be  surprised  to  fuid  a  strictly 
normal  fluoroscopic  picture,  the  lung  being  evenly  illuminated  in  every 
part,  although  Williams's  sign  of  lessened  diaphragmatic  action  may 
generally  be  discoverable.  On  the  other  hand,  in  old  chronic  fibroid  or 
pleuritic  cases,  or  in  cases  with  much  consolidation  or  caseation,  there 
are  large,  irregular  areas  of  shadow,  varying  in  density  from  a  pale 
gray  in  recent  active  lesions  (Figs.  59-62),  to  dense  shadows  in  old  in- 
active chronic  (Figs.  57  and  58)  trouble,  pleural  thickening  (Fig.  63), 
or  effusion  (Fig.  64).  Between  these  two  one  can  find  anything  from 
faint,  slight  mottlings,  to  dense  spots  of  local  shadow  (Fig.  60,  F).  The 
fluoroscope  only  discovers  condensation,  and  by  recalling  the  pathologic 
conditions  in  acute  miliary  tuberculosis,  and  in  old  chronic  cases,  the 
reasons  for  these  findings  are  clear.  The  fluoroscope  gives  information, 
first,  as  to  changes  in  motion;  second,  as  to  changes  in  density;  and  third, 
as  to  changes  in  size  of  the  lung;  or,  more  specifically,  as  to:  (1)  changes 
of  motion  and  position  of  tlie  base;  (2)  increase  or,  more  rarely,  decrease 
in  the  density  of  lung  tissue;  (3)  enlarged  bronchial  glands;  (i)  the 
comparative  size  of  the  two  lungs;  (5)  the  size  and  position  of  the  heart; 
(6)  thickening  of  the  pleura;  (7)  collections  of  fluid  and  air;  (8)  ex- 
cavations of  lung  or  dilatations  of  bronchi.  In  considering  these  changes 
it  is  well  to  discuss  them  as  found:  first,  in  incipient  cases;  second,  in 
moderately  advanced  cases;  and  third,  in  advanced  cases. 

Changes  in  Incipient  Cases. — The  changes  in  incipient  cases  are  not 
numerous  or  pronounced,  but  they  possess  considerable  diagnostic  value, 
although  this  value  is  probably  not  as  great  as  many  radiologists  think. 
AVilliams,  of  Boston,  states  that  cases  where  tuberculosis  is  shown  by 
the  rays  fluoroscopically  before  the  physical  signs  are  diagnostic  are 
common,  those  in  which  the  rays  and  the  signs  both  indicate  the  disease 
are  more  common,  and  those  in  which  the  signs  indicate  tuberculosis 
before  the  rays  do  are  rare.  The  statement  that  usually  the  Eoentgen 
ray  surpasses  auscultation  in  making  an  early  diagnosis  is  widely  at 
variance  with  the  writer's  experience.  In  a  majority  of  cases  a  proper 
physical  examination  will  surpass  the  Eoentgen-ray  fluoroscopic  exami- 
nation in  a  diagnosis  of  incipient  disease. 

The  number  of  cases  examined  by  the  writer  up  to  date  is  very  large. 
In  these  he  has  used  the  Roentgen  ray  for  fluoroscopic  examinations 
under  the  best  conditions,  and  in  the  large  majority  of  cases  physical 
signs  antedated  fluoroscopic  changes.  Walsh  says,  in  disagreeing  with 
Williams's  opinion,  that  he  has  "not  yet  seen  a  case  which  could  be 
proved  to  be  a  case  of  tuberculosis  in  which  the  process  could  not  be 
demonstrated  with  a  careful  (physical)  examination." 


OBJECTIVE   SIGNS 


275 


Beclere  quotes  the  work  of  Kelsch  and  Boinon,  who  in  124  chest 
examinations  of  eases  of  tuberculosis  found  73  absolutely  negative,  which 
would  seem  to  verify  these  views.  Holzknecht  says,  as  a  result  of  autop- 
sies, that  the  cases  of  apical  tuberculosis  diagnosticated  by  the  Roentgen 
ray  are  anatomically  not  cases  of  incipient  tuberculosis,  but  old  shrunken 
foci,  only  showing  activity  in  spots.  Such  cases  are  clinically,  but  not 
anatomically,  tuberculosis.  On  the  other  hand,  in  undoubted  cases  of 
apical  catarrh  one  may  fail  to  find  any  changes,  except  abnormal  dia- 
phragmatic action,  and  at  other  times  extensive  focal  shadows.  This, 
he  believes,  is  due  to  the  fact  that  the  latter,  which  appear  as  in- 
cipient cases,  are  really  exacerbations  in  old  healed  foci.    The  remainder 


Fig.  59. — Anterior  View  of  the  Lungs  in  a  Case  of  Early  Acute  Tuberculo- 
sis OF  THE  Left  Lung.  Note  the  diffused  light  mottling  in  the  upper  left 
side  (G),  showing  the  acuteness  of  the  trouble.  The  peribronchial  glands  on 
both  sides  are  thickened  (F).  At  /  are  seen  calcified  glands  or  tubercles,  and 
the  diaphragm  on  the  right  is  unduly  retracted,  possibly  as  a  result  of  the  peri- 
bronchial trouble.    Compare  the  clear  right  apex  with  the  left,  which  is  clouded. 


of  the  cases  which  are  clinically  doubtful  but  radioscopically  positive,  are 
cases  with  large,  centrally  located  foci  and  with  slight  or  little  catarrh. 
"  The  real!}/  anatomically  incipient  cases — i.  e.,  conglomerate  tubercles 
and  catarrh — am/'  he  says,  "  radioscopically  undeterminable." 

The  incipient  changes  are,  first,  limitation  of  motion  of  the  base; 


276    SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

second,  apex  or,  more  rarely,  other  shadows;  and  third,  shadows  of 
enlarged  bronchial  glands. 

Limitation  of  motion  of  the  diapliragm  on  the  affected  side  was  first 
noticed  by  Williams,  of  Boston,  in  181)7,  and  has  since  been  verified  by 
all  observers.  The  limitation  of  motion  is  at  times  seen  on  one  aspect 
(anterior  or  posterior)  and  absent  on  the  other,  and  in  any  case  motion 
is  most  markedly  limited  in  that  face  of  the  lung  which  it  most  involved 
(Walsham).  A  limitation  of  motion  can  often  be  found  when  no  other 
abnormality  can  be  seen  on  the  screen,  but  the  writer  has  never  found 
limitation  to  exist  in  a  case  where  careful  auscultation  could  not  deter- 
mine incipient  trouble.  Williams,  however,  considers  that  it  may  long 
antedate  any  auscultatory  changes.  The  limitation  has  been  ascribed 
to  various  causes,  but  it  seems  sufficiently  and  best  exj)lained  by  the  loss 
of  elasticity  in  tlie  diseased  portion  of  the  lung  wliich  lessens  its  expan- 
sibility, and  which  also  accounts  for  the  retraction  of  the  apex  border 
shown  by  apical  percussion. 

As  the  process  advances,  loss  of  motion  may  Ijccome  very  marked, 
and  is  present  in  all  well-marked  cases,  and,  if  much  dry  pleurisy  is 
present,  niay  be  absolute.  Diagnostically,  a  slight  limitation  of  motion 
of  the  base  of  one  lung  Avould  raise  other  dubious  symptoms  to  a  very 
high  value,  and  make  a  diagnosis  which  would  otherwise  be  impossible. 
By  itself  limitation  of  motion  is  suspicious,  but  does  not  justif}'  diagnosis. 

Shddiiuj  of  tJic  apex  region  (Figs.  5G,  G  and  GO,  G),  or,  more  rarely, 
small  spots  of  shadow  in  other  regions,  is  the  second  early  sign  of  pul- 
monary tuberculosis  on  the  fluoroscope.  A  shadow  in  the  apex  is  usually 
a  imiform  fogging  over  the  whole  ai'ca,  and  generally  of  only  moderate 
intensity,  and  it  is  often  combined  with  a  decrease  of  apex  area  (Fig.  62). 
At  times  part  of  an  apex  will  be  clear,  and  again,  but  not  often,  there 
is  found  one  small,  sharply  defined  focus,  sometimes  just  behind  the 
clavicle,  more  usually  above  it,  and  very  rarely  elsewhere  in  the  lung. 

Holzknecht  warns  against  mistaking  the  dark  spots  at  times  formed 
in  a  dorsal  image  by  the  crossing  of  the  first  rib  and  sternal  end  of  the 
clavicle  for  an  apex  focus.  In  more  advanced  cases,  with  cavities  in 
the  apex,  these  cavities,  unlike  excavations  elsewhere,  are  not  bordered 
by  dense  shadow  on  the  ui)per  side,  tlie  apex  in  such  cases  simply  appear- 
ing unduly  bright  and  clear,  with  shading  below.  In  certain  early  cases 
the  writer  has  found  the  apex  on  the  involved  side  smaller  than  that  on 
the  sound  side,  though  it  was  not  shaded,  Init  usually  the  shrinkage 
of  the  apex  and  flattening  of  its  domelike  outline,  with  lessening  of  the 
height  above  the  clavicle,  only  occurs  wdicn  trouble  elsewhere  in  the  lung 
has  caused  a  general  shrinkage.  AValsham  considers  a  failure  of  the 
apex  to  light  up  on  deep  expiration  an  excellent  early  sign. 

In  examining  the  apex  for  shadows  it  must  be  remembered  that  this 


OBJECTIVE   SIGNS 


277 


area  is  normally  less  bright  than  the  rest  of  the  lung  from  1)eing  shaded 
by  the  ribs  and  thick  muscles  behind,  but  tliis  need  not  give  trouble,  as 
the  normal  apex  has  a  fairly  clear  outline,  while  the  involved  apex  has 
a  liazy  and  indefinite  one.  The  French  school  of  radiologists  believes 
that  the  right  apex  is  normally  less  bright  than  the  left,  but  the  writer 
is  in  accoi-d  with  the  Germans,  wlio  have  not  recognized  such  a  difference. 
The  diagnostic  value  of  an  apex  shadow  is  great,  but  it  is  not  a 
very  early  apj)earance.     Beclere's  statement  that  the  diminution  of  the 


Fig.  60. — Anterior  View,  SHOW^NG  Enlargement  of  the  Peribronchial 
Glands  Around  the  Roots  Shown  ry  Bunched  Shadows  (F)  on  Each 
Side  of  the  Sternum,  that  on  the  Left  Being  Just  Outside  the  Auricular 
Shadow.  At  the  extremity  of  the  right  bronchial  tree  just  above  the  diaphragm 
are  seen  some  small  calcified  glands  or  tubercles  (7).  The  infiltration  of  the 
right  apex  (G)  extends  downward  and  inward  through  the  sterno-clavicular 
angle  to  the  l)ronchial  glands,  a  common  finding,  and  giving  rise  to  the  ohlif|iiity 
of  the  shadows  of  a])ical  trouble  referred  to  in  the  text.  Compare  the  clouded 
right  with  the  clear  left  apex.     Note  mammary  gland  at  M. 


transparence  of  Ihe  n])ex  to  the  "Roentgen  rays  antedates  hronchopliony, 
dullness,  and  crackles  is  correct,  and  the  writer  has  not  fiuiiid  that  it  can 
antedate  rough  inspiration,  feeble  l)reathing,  or  slight  vesiculo-bronchial 
breathing,  as  it  must  if  it  is  to  precede  ])hysical  signs,  and  when  it  is 
recalled  what  are  the  palbologic  conditions  winch  produce  these  slight 
changes,  it  seems  most  imj)robable  that  they  should  cast  shadows. 


278    SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

The  next  incipient  change,  and  one  which  often  antedates  any  phys- 
ical signs,  is  the  shadow  cast  by  enlarged  bronchial  glands  (Figs.  59,  P; 
60,  F;  61,  F).  These  can  cause  two  forms  of  shading.  The  most  inter- 
esting and  striking,  but  the  least  common,  is  a  hemispherical  or,  at 
times,  a  more  irregular  fusiform  mass  of  shadow  on  one  or  both  sides  of 
the  sternum,  at  the  end  of  the  second  interspace,  or  a  little  lower,  and 
varying  in  density  from  light  gray  to  a  very  dark  gray  or  almost  black, 
and  if  the  shadow  is  not  very  dense,  as  is  the  case  if  the  glands  are  not 
calcified,  it  can  so  merge  into  the  aortic  shadow  (Fig.  64)  as  to  cause 
some  doubt  as  to  its  real  nature  if  it  is  confined  to  the  left  side,  as  it  is 
usually.  The  writer  has  found  these  shadows  quite  frequently  in  cases 
with  incipient  apical  catarrh,  the  enlarged  glands  almost  certainly  ante- 
dating the  latter  by  months  or  years. 

Under  treatment  such  gland  shadows  can  be  seen  to  lessen  notably 
in  size,  and  in  some  cases  shrink  sufficiently  to  disappear  from  view 
behind  the  sternum.  Posteriorly,  such  shadows  can  also  be  seen,  tliough 
not  so  frequently  nor  so  well,  and  stand  out  sharply  to  tlie  left  or  right 
side  of  the  spinal  column,  about  the  level  of  the  spine  of  tlie  scapula, 
or  again  may  show  themselves  as  a  fusiform  widening  or  thickening  of 
the  spinal  shadow  at  this  point.  A  large  glo])ular  enlargement  of  the 
tracheobronchial  glands  will  at  times  be  found  in  syphilis,  and  as  syph- 
ilis may  cause  severe  cough  and  physical  signs  in  the  lung,  it  may  be 
mistaken  for  tuberculosis. 

The  more  common  type  of  shadow  cast  by  the  bronchial  glands  is 
seen  around  the  root  of  the  lung  and  along  the  main  bronchus  around 
the  accompanying  shadow  (Figs.  57,  58,  59,  61,  63).  On  the  left  side 
this  accompanying  shadow  almost,  or  actually,  touches  the  heart  shadow. 
On  the  right  side  it  stands  out  plainly  outside  the  sternum.  When  the 
bronchial  glands  are  enlarged,  and  more  especially  when  they  are  calci- 
fied, this  faint,  ghostlike  ribbon  shadow,  which  narrows  and  fades  away 
normally  about  the  level  of  the  fifth  rib,  becomes  thicker,  darker,  can 
be  traced  further,  and  is  closely  surrounded  by,  or  mingled  with,  lumpy 
shadows  of  greater  density  (Fig.  57).  Schellenberg  considers  that  ir- 
regular and  pronounced  hilus  markings  are  always  pathologic,  and 
Koehler  believes  that  only  calcified  glands  or  large  masses  can  be  rec- 
ognized by  the  fluoroscope.  While  the  writer  has  not  been  al)le  to  follow 
any  of  his  cases  to  autopsy,  the  clinical  histories  of  certain  of  them  lead 
him  to  think  this  statement  is  too  broad,  and  that  glands  of  very  moder- 
ate size,  say  the  size  of  a  cherry,  can  he  seen.  The  shadows  are  usually 
seen  close  to  the  sternum,  but  at  times  farther  down  along  the  accom- 
panying shadow,  making  a  small  mass  of  shading  just  to  the  left  of  the 
heart  border  (Fig.  61),  which  may  be  demonstrated  by  percussion,  and 
which  is  probably  due  to  enlarged  peribronchial  glands. 


OBJECTIVE   SIGNS 


279 


From  beliind  they  are  quite  frequently  seen  on  the  right  side  as  a 
dark  streak  bet\veen  the  scapula  and  the  spinal  column  (Fig.  62),  run- 
ning from  the  hilus  downward  and  outward,  parallel  to  the  inner  border 
of  the  scapula.  As  before  noted,  the  shadow  of  this  inner  border  must 
not  1)0  mistaken  for  them.  On  the  right  side,  owing  to  the  proximity  of 
the  heart  and  scapula  shadows,  they  are  not  easily  seen.  The  detailed 
study  of  such  glands  can  be  made  with  certainty  with  the  fluoroscope. 


Fig.  61. — Anterior  View  of  the  Lungs  in  an  Old  Case  of  Nineteen  Years' 
Standing,  Showing  Groups  of  Calcified  Tubercles  (/)  and  also  Thicken- 
ing (F)  Around  the  Right  and  Left  Bronchi.  The  dark  patches  (M)  on 
each  side  caused  by  the  mammary  glands  must  not  be  mistaken  for  infiltra- 
tion. At  A  the  normal  markings  are  well  seen;  these,  as  noted  in  the  text, 
are  not  seen  with  the  fluoroscope.     Both  apices  are  shaded. 


although  small  calcified  nodules,  a  quarter  of  an  inch  or  less  in  diameter, 

which  radiologists  show  on  their  plates  (Fig.  62,  I)  will  be  overlooked. 

In  incipient  cases  with  congenitally  poor  chests  the  fluoroscope  draws 

attention  very  graphically  to  the  oblique,  narrow  interspaces  and  the 


280    SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

acute  angle  wliich  the  ribs  make  with  tlie  sternnni.  Undue  smallness 
of  the  lieart,  so  common  in  tliis  disease,  is  made  especially  evident  by 
this  measure,  and  the  percentage  of  cases  witli  small  hearts  is  shown 
by  its  use  to  Ije  very  large. 

In  moderately  advanced  trouble  there  are  increasing  degrees  of 
shadow  extending  downward  from  the  apex  to  the  second  or  third  ribs, 
and  just  as  the  line  of  percussion  dullness  is  very  apt  to  run  obliquely 
from  without  and  above,  downward  and  inward,  so  on  the  iluoroscope 
one  is  often  struck  with  the  marked  obliquity  of  the  lower  border  of 
the  shadow  (Figs.  56,  GO,  63),  which  in  chronic  and  favorable  cases  is 
sharply  demarcated  from  the  underlying  clear  lung.  Very  frequently, 
while  the  apex  is  still  clear,  the  claviculosternal  angle  will  be  filled  with 
a  small  triangular  area  of  shadow,  but,  as  has  been  noted,  this  may  be 
simulated  in  some  degree  by  a  large  first  ril)  at  its  junction  with  the 
sternum.  Claude,  quoted  by  Cassaet,  considers  a  lack  of  distinctness  of 
the  clavicular  shadow  in  comparison  to  that  in  the  sound  side  a  good 
sign  at  this  stage.  While  in  favorable  and  not  very  active  cases  there  are 
quite  sharply  marked  borders  and  more  or  less  even  shadows  (Fig.  63), 
in  cases  M'ith  more  activity  there  will  l)e  a  general  diffuse  mottling  (Figs. 
56,  59),  or  the  advancing  1)order  of  the  trouble  will  be  hazy  and  ill-de- 
fined (Fig.  64).  Very  frequently  the  Avhole  area  between  the  clavicle 
and  the  fourth  or  fifth  rib  is  thus  mottled  over  with  shadows  (Fig.  56) 
separated  Ijy  relatively  or  entirely  clear  areas,  this  having  a  distinctly 
bad  prognostic  meaning. 

When  it  is  remembered  that  the  more  sharply  defined  dark  shadows 
represent  old  areas  of  infiiltration  and  more  chronic  process,  and  the 
lighter  indefinite,  gray,  mottled  shadows  active  and  more  recent  trouble, 
a  fact  Avhich  soon  becomes  evident  to  one  working  much  with  the  fluoro- 
scope,  it  will  be  possible  to  inter])rot  findings  much  more  satisfactorily. 

As  a  rule,  the  base  of  the  lung,  if  free  from  fluid  or  pleural  thick- 
ening, will  remain  clear  even  in  very  advanced  cases  (Fig.  56),  and  a 
uniform  shading  from  apex  to  base  generally  means  a  thickened  pleura. 
The  writer  has  frequently  found  in  the  left  lung  an  isolated  focus  of 
trouble,  which  can  easily  be  overlooked  by  perciission  and  auscultation, 
lying  under  the  left  axillary  fold,  halfway  between  the  heart  and  the 
outer  border  of  the  lung  area.  A  few  times  he  has  found  in  the  lung, 
seen  from  behind,  dark  oblique  lines  running  from  within  downward 
and  outward,  and  only  visible  from  certain  levels ;  these,  Holzkneclit 
says,  are  due  to  interlobar  pleurisy.  That  congestions  of  the  lung  can 
give  shadows  is  asserted  by  Pf abler.  That  the  conditions  existing  in 
simple  congestion  of  the  lung  could  cause  a  shadow  seems  remarkable, 
and  such  a  claim  would  have  to  be  abundantly  supported  by  autopsies  be- 
fore it  can  win  general  acceptance.     As  the  writer  never  rays  patients 


OBJECTIVE   SIGNS 


281 


who  have  an  active  disease  and  fever^  he  has  not  been  able  to  determine 
this  point  by  experiment. 

Em2:)hysema,  if  very  general,  can  be  seen  as  an  undue  translucence  of 
the  lunij,  but  the  writer  has  not  been  able  to  recognize  the  small  areas  of 


Fig.  62. — A  Posterior  View  of  an  Infiltrated  Left  Apex  (G'j  with  Slight 
Retraction  of  the  Heart  (B)  to  the  Left.  Note  the  general  shrinkage  of 
the  left  side  as  compared  with  the  undue  size  of  the  right,  which  is  coni])ensa- 
torily  enlarged.     A  calcified  tubercle  is  seen  at  /. 


localized  emphysema  which  arc  its  commonest  form  in  tidjcrculosis,  or 
use  it  to  discover  areas  of  compensatory  emphysema  around  healing  foci. 
It  is  in  this  stage  that  there  is  ascension  of  the  liver  (Fig.  o!»)  through 
shrinkage  of  the  lung,  the  diaphragmatic  shadow  often  reaching  high 
enough  to  touch  the  angle  of  the  scapula  behind  or  the  fifth  rib  in  front. 


282 


SYMPTOMATOLOGY  OF   PULMONARY  TUBERCULOSIS 


Pleural  thickening  usually  manifests  itself  as  a  diffuse,  moderately 
dense  shadow  over  large  areas  (Fig.  56),  without  any  mottling,  and,  as 
Pfahler  says,  "  shading  gradually  at  its  edge  into  the  surrounding  clear 
space."  As  clinical  experience  would  lead  one  to  expect,  such  shadows 
are  commonest  at  the  lateral  base,  cutting  down  or  filling  up  the  costo- 
diaphragmatic  angle  until  the  outline  of  the  lower  long  border  runs  in 
a  curve  from  the  heart  apex  upward  into  the  axilla.  The  writer  has 
found  such  pleuritic  shadings  commonest  at  the  base  behind,  but  Holz- 
knecht  thinks  they  are  most  pronounced  in  front.  Such  patients  will 
show  little  or  no  shading  at  the  base  on  one  aspect,  and  a  large  shadow 
when  turned  to  the  other.     In  this  stage  is  also  found  quite  frequently 


Fig.  63. — Anterior  View.  In  the  upper  left  lung  a  thickened  jjleura  easts  an 
even  smooth  shadow  not  very  dense  (R),  so  that  the  lung  markings  can  be  seen 
through  it.  Both  apices  are  infiltrated  and  around  the  bronchi  is  some  thicken- 
ing extending  down  to  their  ends  at  the  diaphragm. 

a  marked  decrease  in  the  size,  and  more  especially  in  the  width,  of  the 
lung  area  (Fig.  62),  while  it  is  still  almost  clear  and  about  normal  in 
shape,  except  for  a  little  rounding  off  of  the  costodiaphragmatic  angle. 

Small  pleuritic  effusions  the  writer  has  not  found  often,  since,  when 
they  are  small  enough  to  lie  below  the,  level  of  the  arch  of  the  dia- 
phragm they  can  be  hidden  by  its  shadow  and  totally  overlooked,  unless 
the  level  of  the  tube  is  changed  or  the  patient  is  rotated  on  his  vertical 


OBJECTIVE   SIGNS  283 

axis  po  as  to  get  the  costodiaphragmatic  angle  in  profile.  When  such 
effusions  are  larger  (see  Fig.  64)  they  usually  show  themselves  as  dark 
shadows  with  distinct  upper  borders,  having  a  curved  outline,  similar  to 
that  obtained  on  percussion.  Their  change  of  level  on  motion  is  not  as 
rapid  as  the  instantaneous  alteration  in  a  pyopneumothorax.  Their 
effect  on  the  position  of  the  heart,  if  of  any  size,  can  plainly  be  seen. 

The  fluoroscope  will  not  infrequently  disclose  an  unsuspected  peri- 
cardial effusion  or  a  dilatation  of  the  right  ventricle  (Fig.  56),  The 
former  produces  a  pale  gray  shadow  extending  more  or  less  outside  of 
the  heart  shadow,  but  roughly  paralleling  its  outline.  The  contrast  be- 
tween the  density  of  the  two  shadows  is  so  clear  as  to  be  diagnostic. 
Such  shadows  are  much  more  pronounced  on  the  right  side  than  on  the 
left,  and  are  better  seen  from  behind  than  in  front  (Fig  56).  Dilata- 
tion is  seen  as  an  extension  of  the  heart  shadow  outside  its  normal  area 
and  is  commoner  than  percussion  would  lead  one  to  believe. 

While  the  writer  has  seldom  found  shadows  where  careful  physical 
examination  could  not  demonstrate  signs,  he  has  been  frequently  sur- 
prised in  cases  with  considerable  auscultatory  signs  and  with  marked 
symptoms  to  find  a  normal  fluoroscopic  picture.  This  has  been  espe- 
cially the  case  in  those  patients,  chiefly  young  girls,  who  have  the  phys- 
ical signs  of  an  acute  miliary  tuberculosis,  but  whose  disease  runs  a 
relatively  chronic  course,  from  one  to  three  years,  with  alternations 
between  periods  of  fair  health  and  active  symptoms,  and  who  uniformly 
have  pronounced  tachycardia.  Pathologically  there  must  be  numerous 
miliary  tubercles  which  develop  much  more  slowly  than  usual,  and  since 
the  fluoroscopic  examination  demonstrates  only  condensation,  it  is  natu- 
ral that  such  scattered  small  noncalcified  tubercles  entirely  escape. 

All  writers  on  the  subject  note  that  in  patients  with  scoliosis  there 
are  apt  to  be  areas  of  even  shading  in  various  spots  which  are  not  due 
to  a  tuberculous  deposit,  and  that  in  such  cases  even  areas  of  shadow 
must  not  be  accepted  as  evidence  of  trouble. 

In  advanced  cases,  in  addition  to  the  conditions  already  noted,  there 
is  very  extensive  shading  and  mottling  over  one  or  both  lungs,  and 
signs  of  excavation  (Figs.  56,  57,  58).  The  demonstration  of  cavities 
by  the  X-ray,  when  feasible,  is  most  satisfactory  and  graphic,  but  it  is 
sometimes  surprising  that  cavities  of  considerable  size,  owing  to  the  con- 
dition of  the  surrounding  lung,  may  be  overlooked.  .Tust  as  a  cavity  must 
be  sufficiently  superficial  and  large  to  be  discovered  by  auscultation  and 
percussion,  so  here,  though  to  a  much  less  degree,  they  must  satisfy 
certain  conditions ;  they  must  not  be  too  deeply  seated,  must  not  be  full 
of  secretion,  and  while  they  must  not  be  cut  off  from  the  surface  by 
too  thick  an  area  of  diseased  lung,  they  must  be  surrounded  by  con- 
densed lung,  a  condition  practically  always  existing  except  in  bronchi- 


284 


SYMPTOMATOLOGY  OF   PULMONARY  TUBERCULOSIS 


ectatic  cavities.  Large  cavities  can  entirely  escape  one  in  a  fluoroscopic| 
examination  when  smaller  ones  will  be  seen  distinctly.  When  the  fluoro- 
scope  shows  a  cavity,  reliance  may  be  placed  on  its  evidence,  but  failure' 
to  find  on  the  screen  a  cavity  of  whose  existence  there  are  distinct 
physical  signs  need  not  at  all  shake  our  faith  in  the  diagnosis.  When 
seen  they  show  up  as  a  more  or  less  circular  or  irregularly  oval  bright  spot 
surrounded  Ijy  a  sharply  defined  dark  wall,  which  merges  gradually  on  its 
outer  border  into  the  surrounding  lung  tissue,  which  is  always  more  or 


Fig.  64. — ^Anterior  View  of  the  Lungs  in  a  Case  of  Pleurisy  with  Effu.sion 
AT  the  Right  Base  with  the  Typical  Dense  Smooth  Black  Shadow  Cast 
BY  Fluid  (V).  The  infiltration  around  the  roots  of  the  lungs  would  suggest 
tuberculosis,  but  the  ffiiid  was  traumatic  (fractured  rib). 


less  infiltrated  (Figs.  57,  K;  58,  K).  Holzknecht  considers  they  must  be 
the  size  of  a  walnut  to  Ije  discoverable,  and  I  have  never  discovered  any 
smaller  than  this,  though  some  claim  to  have  found  much  smaller  ones. 
Bronchiectatic  cavities,  when  visible,  are  seen  as  lines  or  chains  of 
radiating  c.ylindrical,  or  more  or  less  spherical,  shadows  running  down- 
ward and  outward,  but  they  can  only  be  diagnosed  if  at  different  exam- 
inations the  shadows  are  sometimes  absent  and  sometimes  reap])ear, 
their  absence  being  coincident  with  the  expectoration  of  large  amounts 


OBJECTIVE   SIGNS  285 

of  sputum.  Their  a])Sonce  when  empty  is,  of  course,  explainahle  l\v  the 
fact  that,  being  surrounded  by  nornuil  lung  tissue,  there  is  not  sutTicient 
contrast  to  demonstrate  them. 

In  view  of  the  seriousness  of  tlie  syni])toms  of  pneumotliorax  one 
will  not  usually  have  the  op])ortu7iity  of  examining  patients  with  a  sim- 
ple pneumotliorax.  It  is  reported  by  those  who  have  seen  it  to  be  a 
brilliant  reflex  over  the  whole  lung,  except  at  its  root.  More  usually 
the  case  will  liave  reached  the  stage  of  hydro-  or  ])neumothorax  before 
it  is  seen.  Xo  condition  demonstrable  by  the  fluorosco})e  is  so  striking 
as  this,  and  only  the  fluoroscope  can  show  those  motions  in  the  fluid 
which  are  an  essential  part  of  tlie  picture. 

The  upper  portion  of  the  affected  side  of  the  thorax  shows  around 
the  hilus  of  the  lung  a  small,  dark  bunch  of  diseased,  retracted  lung. 
Around  and  beneath  this  is  an  area  of  l>rilliant  light,  bounded  1)elow, 
at  a  varying  level  according  to  the  amount  of  fluid,  by  an  absolutely 
horizontal  line  of  blackness,  the  line  changing  level  aljsolutely  and  im- 
mediately with  change  of  position,  and  showing  commotion  if  the  patient 
is  shaken,  and  slight  waves  produced  by  the  heart  action.  The  heart,  if 
the  pneumotliorax  is  on  the  left,  is  displaced  into  the  right  side. 

Dextrocardia,  and  other  cardiac  displacements,  are  very  commonly 
seen  with  the  fluorosco])e.  Quite  early  one  will  find  slight  degrees  of 
displacement  toward  the  riglit  in  riglit-sided  trouble,  or  toward  the  left 
in  left-sided  trouljle  (Fig.  G2),  and  as  fibrosis  increases  this  becomes 
more  and  more  pronounced.  The  heart  is  often  at  first  equally  bisected 
by  the  sternal  shadow  (Fig.  57),  but  in  extreme  cases  disappears  entirely 
from  the  left  side,  or  if  the  trouble  is  on  the  left,  it  is  drawn  far  over 
toward  the  axilla.  Finally,  until  the  physician  becomes  thoroughly  famil- 
iar with  its  technic  he  will  find  difficulty  in  seeing  the  shadows  on  the 
screen  distinctly  enough  to  gain  from  it  the  information  it  can  give.  He 
will,  if  he  persists  in  its  use  under  proper  conditions,  be  surprised  at  how 
much  ho  can  see,  what  assistance  he  can  get  from  it,  and  how  soon  he 
will  l(>arn  to  interpret  the  shadow  picture  correctly. 

Blood. — The  pallor  which  is  so  often  seen  in  phthisis,  and  which 
gave  to  the  disease  the  name  of  the  "  Great  White  Plague,"  would  lead 
one  to  expect  that  the  blood  changes  would  be  very  pronounced  and  an 
examination  of  the  blood  of  great  value  in  a  study  of  pulmonary  tuber- 
culosis. While,  however,  in  advanced  cases,  the  alterations  in  the  blood 
may  be  marked,  in  early  ones  they  are  slight  or,  not  infrequently, 
entirel}'  absent,  and,  as  Keinert  says,  "  in  no  other  disease  is  the  dispro- 
portion between  the  appearance  of  the  patient  and  the  condition  of  the 
blood  so  great  as  in  pulmonary  tuberculosis,"  or,  to  quote  Laache, 
"Phthisis  in  itself  gives  rise  to  no  mai'kcd  anemia  in  most  cases." 

Hematology  is  so  new  a  branch  of  medicine,  and  the  blood  findings 


286    SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

in  tuberculosis,  until  recent  3'ears,  have  been  so  little  studied,  that  all 
but  the  more  recent  writers  on  the  subject  have  had  little  to  say  about 
it,  so  good  an  authority  as  Fox  saying,  as  late  as  the  later  eighties, 
"  there  is  nothing  definite  known  about  the  state  of  the  blood."  Even 
to-day,  after  Ehrlich's  work  has  placed  the  study  of  the  blood  on  a  sci- 
entific basis,  the  physician  is  still  unable  to  draw  from  it  much  infor- 
mation in  pulmonary  tuberculosis,  though  the  recent  work  of  Arneth 
('05),  if  verified,  promises  to  be  of  great  importance  in  enabling  us  to 
form  a  prognosis  from  a  study  of  the  nuclear  structure  of  the  white  cells. 

Most  of  our  knowledge  of  the  subject  up  to  the  present  date  has 
come  from  the  work  of  Grawit?,  Limbeck,  and  Appelbaum,  no  very 
promising  original  work  having  followed  theirs  until  that  of  Kjer-Peter- 
Ben  and  Arneth. 

In  the  first  stage  of  the  disease  we  will  usually  find  a  moderate 
degree  of  chlorosis.  The  chlorosis  of  this  stage  differs  from  a  real  chlo- 
rosis in  several  respects,  and  has  been  called  a  tuberculous  pseudo- 
chlorosis  or  chloro-anemia ;  but  as  it  is  often  mistaken  for  real  chlorosis, 
it  leads  frequently  to  unfortunate  delays  in  diagnosis  and  treatment, 
and  the  importance  of  thinking  of  the  possibility  of  incipient  tubercu- 
losis in  every  case  of  chlorosis  cannot  be  insisted  on  too  emphatically. 
French  writers  (Herard,  See,  Papillon)  would  distinguish  it,  first,  by 
the  hue  of  the  facies,  which  is  not  that  peculiar  pale  greenish  pallor  so 
characteristic  of  the  "  gi-een  sickness,"  but  a  dirty  yellowish-gray  or 
bluish-gray;  second,  by  the  weakness  or  absence  of  the  souffle  in  the 
vessels  of  the  neck  (bruit  de  diable)  which  is  so  pronounced  in  chlorosis; 
third,  by  the  presence  of  marked  fever,  tachycardia,  and  unduly  forcible 
heart  beat;  and  fourth,  by  emaciation,  the  real  chlorotic  usually  being 
plump.  Laache  and  Sorensen  note  that  the  mucous  membranes  in  tuber- 
culous chlorosis  are  not  pale  as  in  real  chlorosis. 

In  the  second  stage,  if  the  patient  is  undergoing  a  hygienic  cure, 
he  usually  has  a  normal  color,  but  in  advanced  cases  pallor  is  the  rule, 
often  extreme,  the  skin  being  ghastly  pale,  except  where  two  bright  spots 
of  hectic  flush  ominously  light  up  the  sunken  cheeks. 

The  morphologic  changes  in  the  blood  in  pulmonary  tuberculosis  are 
not  very  pronounced.  The  red  cells  show  no  very  marked  decrease  in 
number,  except  in  the  last  stage.  T^sually  the  erythrocytes  are  mod- 
erately reduced  in  the  first  stage,  normal  in  the  second  stage,  and  mod- 
erately or  at  times  greatly  reduced  in  the  third  stage.  Sokolowski  gives 
the  count  for  the  first  stage  as  from  three  to  six  millions,  for  the  second 
stage  five  to  six  millions,  and  for  the  third  stage  two  to  four  millions. 
Ullom  and  Craig  ('05),  in  39  cases,  found  an  average  of  4,510,000  in  the 
first  stage,  4,630,000  in  the  second  stage,  and  4,297.000  in  the  third  stage. 
Brown    ('07)    reports  5,502,410  as  the  average  of  80  first-stage  cases. 


OBJECTIVE   SIGNS  287 

and  5,680,556  as  the  average  of  75  advanced  cases.  In  this  connection, 
however,  it  must  be  remembered  that  Brown's  patients  were  undergoing 
a  hygienic  cure,  which  tends  greatly  to  raise  the  blood  count.  In  the 
first  stage,  as  already  noted,  the  findings  were  those  of  a  moderate 
chlorosis,  and  Cabot  notes  that,  unlike  this  trouble,  in  which  a  majority 
of  the  cells  are  small  and  pale,  in  tuberculosis  only  some  of  them  show 
such  alteration,  combined  with  a  slight  decrease  in  total  numbers.  Poi- 
kilocytosis  is  rare,  and  nucleated  red  cells  are  very  rare  (Emerson,  '06). 

In  the  second  stage  the  slight  anemia  of  the  incipient  stage  is  lost, 
this  being  generally  conceded  to  be  due  to  a  lessening  of  the  total  amount 
of  blood  by  concentration,  which  produces  a  relative  excess  of  sojids, 
pigment,  and  red  cells  (Sokolowski,  '06).  This  is  due,  according  to 
Grawitz,  to  the  effect  of  the  toxins  of  the  bacillus  which  produce  a 
transudation  of  serum  from  the  blood  into  the  tissues,  or,  according  to 
Dehio  and  Appelbaum  {'02),  to  the  drain  on  the  serum  by  the  sweats 
and  profuse  expectoration.  Emerson  notes  that  the  hypercythemia  of 
this  stage  is  said  to  be  compensatory  for  the  dyspnea. 

In  advanced  cases  there  is,  with  rare  exceptions,  a  fairly  pronounced 
anemia,  with  a  moderate  decrease  of  red  cells,  produced  by  the  septi- 
cemia of  the  mixed  infection.  L.  Brown  found  the  red  cells  rarely 
under  3,000,000,  but  a  few  pronounced  anemias  with  very  low  readings. 
The  number  of  the  red  cells  can  be  lessened  markedly  during  and  just 
after  hemorrhages,  and  increased  greatly  during  a  hygienic  cure.  Pleth- 
ora may  be  so  pronounced  as  to  have  a  causative  relation  to  bleeding. 

The  form  of  the  red  cells,  except  for  that  pallor  and  decrease  in  size 
already  referred  to,  is  considered  by  most  observers  to  remain  unchanged, 
but  Maragliano,  quoted  by  De  Eenzi,  describes  numerous  changes  in  the 
morphology  of  the  cells,  wliich  he  thinks  may  be  found  in  the  incipient 
stages  as  well  as  later.  Cabot  and  Emerson  consider  that  marked  changes 
in  shape  only  occur  in  severe  mixed  infections.  According  to  Maragli- 
ano, the  red  cells  have  not  only  a  reduced  diameter,  but  the  central  zone 
is  more  distinct,  with  beginning  degeneration,  and  the  periphery  shows 
sharp  projections  and  an  ellipsoid  form.  In  late  cases  he  considers 
poikilocytosis  and  microcytosis,  with  granulation  and  destniction  of  the 
red  cells,  characteristic.  Malassez  notes  that,  as  a  rule,  the  red  cells 
are  decreased  in  number  with  advance  of  tlie  trouble,  and  increased  with 
its  improvement. 

Coloring  Matter. — Tlie  hemoglobin  is  moderately  reduced  in  the 
first  stage,  normal  in  the  second,  and  considerably  reduced  in  the  third. 
Sokolowski  gives  it  as  43  to  95  per  cent  in  the  first,  72  to  104  per  cent 
in  the  second,  and  40  per  cent  in  the  third  stage.  Reimert  notes  that 
in  tuberculous  pseudocldorosis  the  reduction  of  hemoglobin  is  much 
less  than  in  real  chlorosis.     As  a  result  of  the  reduction  of  the  hemo- 


288  SYMPTOMATOLOGY   OF   PULMONARY  TUBERCULOSIS 

globin,  Grancher  notes  that  the  respiratory  vahie  of  the  cell  is  lessened 
and  the  oxygen  intake  decreased,  the  absorption  of  oxygen  falling  from 
28  to  30  c.c.  to  the  hundred  to  23  to  24  c.c.  This  decrease  of  hemo- 
globin is  not  accompanied  by  any  lessening  of  the  iron  content,  which' 
is  proportionately  increased.  Very  characteristic  of  the  first  stage  is 
the  fact,  first  noted  by  Neubert,  that  the  hemoglobin  is  more  markedly 
decreased  than  is  the  number  of  red  cells,  but  in  the  second  stage  it  is 
compensated  for,  the  readings  being  usually  normal  or  above  normal. 

The  leucocytes  in  tuberculosis  until  recently  have  only  been  studied 
numerically  and  in  difPerential  counts.  In  the  first  and  second  stages 
they  are  normal,  while  in  the  third  stage,  as  in  all  other  chronic 
cachexias,  they  are  increased  in  number.  ITllom  and  Craig  found  them 
to  average  10,285  in  the  first  stage,  12,772  in  the  second,  and  14,041  in 
the  third.  As  long  as  the  infection  is  purely  a  tuberculous  one,  even 
if  it  is  acute  (Sahli),  the  white  cells  are  unaffected,  the  leucocytosis  of 
the  third  stage  being  the  evidence  of  the  development  of  a  mixed  infec- 
tion (Limbeck,  '96),  and  hence  a  leucocytosis  speaks  for  softening  or 
cavity  formation,  or  for  the  development  of  some  complication,  such 
as  hemorrhage,  pneumonia,  or  fever.  While,  however,  usually  developing 
with  excavation,  "  absence  of  leucocytosis  cannot  l)e  considered  to  exclude 
the  existence  of  cavities,  as  has  been  claimed  l)y  Stein  and  Erbmann  ('98), 
though  it  would  probably  exclude  one  of  any  consideral>]e  size."  When 
present,  leucocytosis  is  usually  of  the  polymorphonuclear  variety  and 
eosinophil ia,  except  after  the  use  of  tuberculin  or  at  the  menses,  is  absent. 

Holmes  ('96)  reported  that  he  was  able  to  estimate  the  resistance 
of  the  patient  by  a  differential  count  of  the  leucocytes,  but  his  Avork  has 
not  been  confirmed  1)y  other  observers.  Ullom  and  Craig  ('05)  con- 
sider that  probably  an  increase  of  leucocytes  is  an  imfavoral)le  sign  in 
advanced  tuberculosis,  and  venture  the  suggestion  that  lymphocytes  have 
a  dii'ect  relation  to  the  resistance  of  the  system  to  the  disease.  Within 
the  last  year  Craig  ('07)  has  made  a  careful  study  of  the  various  types 
of  leucocytes  found  in  tuberculous  blood,  and  was  unable  to  draw  any 
definite  prognostic  conclusions.  Therefore,  until  the  work  of  Kjer- 
Petersen  and  Arneth,  the  only  conclusions  that  could  be  drawn  from 
the  blood  examination  in  tuberculosis  were  as  to  the  existence  or  absence 
of  a  mixed  infection.  Kjer-Petersen  ('06),  quoted  by  A.  C.  Klebs, 
agrees  with  Stein  and  Erbmann,  who  believe  that  an  increase  of  leuco- 
cytes in  tuberculosis,  if  there  is  not  a  chronic  inflammatory  process, 
speaks  for  cavity  formation  in  tlie  lung,  that  the  beginning  of  cavity 
formation  can  be  determined  by  a  sudden  increase  of  leucocytes  after 
a  prolonged  normal  period,  and  that  cavity  formation  can  be  excluded 
if  normal  numerical  conditions  are  found.  Arneth  ('05)  followed  a 
different  method  than  any  other  observer,  not  studying  the  numbers  of 


OBJECTIVE   SIGNS  289 

the  different  varieties  of  leucocytes,  but  devoting  his  attention  to  the 
neutrophile  cells  and  determining  the  numbers  of  those  with  one,  two, 
three,  four,  or  five  nuclear  fragments.  Quoting  Klebs  ('06),  who 
reviewed  his  work: 

A  neutrophile  of  Class  I,  with  an  absolutely  round  nucleus,  he  desig- 
nates as  a  myelocyte  (M.)  ;  the  other  forms  in  this  class,  with  more  or  less 
indented  nuclei,  which  he  thinks  correspond  to  the  polymorphonuclears  of 
other  authors,  he  calls,  in  accordance  with  the  degree  of  indentation:  W. 
(wenig)  for  slight,  T.  (tief)  for  deep  indentations.  In  other  classes  he 
notes  whether  there  are  nuclei  in  the  shapes  of  loops  S.  (Schlinge)  or  round 
nuclear  particles,  K.  (runder  Kernteil).  .  .  .  The  various  combinations  of 
loops  and  round  nuclei  in  the  neutrophiles  and  the  three  groups  in  Class  I 
give  a  total  of  twenty  subdivisions  of  his  original  five  classes.  This  seems 
at  first  very  complex,  but  after  some  experience  one  learns  to  classify  the 
cells  rapidly,  according  to  their  respective  subdivisions,  provided  one  has 
a  well-stained  specimen. 

By  arranging  the  numbers  found  in  tables  horizontally,  one  next  to  the 
other,  beginning  with  Class  I  at  the  left  end,  he  receives  what  he  calls  a 
"  neutrophilic  blood  picture."  He  finds  this  picture  altered  in  pathological 
conditions,  though  not  parallel  with  the  changes  in  the  total  number  of 
leucocytes.  He  can  find  a  profound  alteration  of  the  blood  picture  with  a 
perfectly  normal  leucocyte  count.  The  cells  with  the  more  complex  nucleus 
(higher  classes)  Arneth  thinks  are  the  riper  and  more  efiicient  ones,  while 
the  others  are  the  youthful  and  therefore  less  efl&cient  type  (contrary  to 
Holmes).  The  pathological  alterations  of  the  blood  picture  are  charac- 
terized by  the  disappearance  or  decrease  of  the  cells  from  one  class,  and 
the  appearance  or  increase  of  cells  in  another;  one  can  then  speak  of  a 
shifting  of  the  blood  picture  to  the  left  or  to  the  right.  By  a  great  number 
of  examinations  of  the  blood  picture  .  .  .  Arneth  has  been  able  to  demon- 
strate a  constant  and  direct  relation  between  the  course  of  the  disease  and 
the  relations  of  the  picture.  The  latter  are,  threfore,  an  index  of  the 
defensive  and  protective  efforts  of  the  body  against  infection.  Arneth's 
normal  neutrophilic  blood  picture  in  a  case  where  the  actual  leucocyte 
count  was  5,500: 


I 

II 

III 

IV 

V 

5% 

35% 

41% 

17% 

2% 

This  "  illustrates  a  normal  distribution  of  various  neutrophilic  cell  types. 
We  see  that  the  types  of  Classes  II  and  III  predominate,  with  a  fair  per- 
centage of  cells  in  Class  IV.     In  the  picture  next  given, 

I  II  III  IV  V 

36%  56%,  S%  —  — 

of  a  case  of  acute  miliary  tuberculosis,  the  patient  dying  nine  days  later, 
.  .  .  we  can  observe  the  typical  shifting  of  the  picture  to  the  left;  prac- 
tically all  the  cells  are  crowded  into  the  first  two  classes.     Onlj'  the  more 
20 


290  SYMPTOMATOLOGY  OF   PULMONARY  TUBERCULOSIS 

youthful  elements  are  left  to  carry  on  the  struggle,  and  this  condition 
increases  with  the  progress  of  the  case.  The  total  leucocyte  count  is  low, 
4,400."      The  next  picture, 

I  II  III  IV  V 

14%  56.5%  24.5%  4.5%  0.5% 

is  from  a  patient  with  extensive  pulmonary  lesions  and  signs  pointing  to 
a  considerable  activity  of  the  process.  The  number  of  leucocytes  is  only 
slightly  increased,  while  the  blood  picture  is  markedly  shifted  to  the  left. 
Prognostically,  from  every  viewpoint,  this  is  a  bad  case.  The  total  leuco- 
cyte count  is  7,600. 

The  next  two  were  obtained  from  far-advanced  cases  with  extensive 
pulmonary  lesions;  in  the  first  the  leucocyte  count  was  8,400,  and  in  the 
second  27,080: 

I  II  III  IV  V 

55%  38.5%  5.5%  0.5%  0.5% 

I  II  III  IV  V 

29.5%  60%  9%  1.5%  — 

From  liis  own  series  of  examinations,  Klebs  states,  as  regards  the 
normal  neutrophilic  "  blood  pictures,"  that  tlie}'  show  similar  rel^ions 
to  those  obtained  by  Arneth  in  healtliy  individuals  and  that  a  dis- 
tinct nniforniitv  of  results  is  quite  striking,  as  well  as  the  ratios  of  dis- 
tribution of  the  five  different  t3'pes  of  cells.  In  this  regard  he  confirms 
Arneth's  findings. 

The  technie  of  the  method  is  quite  simple;  particular  attention  is  neces- 
sary to  insure  thin  blood  smears.  Undue  pressure  in  spreading  the  blood 
on  the  glass  can  lead  directly  or  indirectly  to  a  distortion  of  the  cells,  and 
so  change  the  picture.  The  stain  used  by  Arneth  is  the  triacid  solution  of 
Ehrlich,  not  a  good  nuclear  stain.  .  .  .  For  this  reason,  Wright's  stain  has 
been  employed  in  most  instances  with  better  results.  .  .  .  The  accurate  and 
minute  classification  of  the  cells  constitutes  the  principal  difficulty  of  the 
method.  The  proper  distribution  of  the  cells,  however,  into  the  principal 
classes  is  not  so  difficult,  and  for  practical  clinical  purposes  this  probably 
suffices. 

Arneth  ('05),  describing  a  "blood  picture"  from  a  case  of  acute 
miliary  tuberculosis  with  6,700  cells,  as  follows: 

I  II  III  IV  V 

42%  53%  5%  —  — 

says : 

Almost  all  the  cells  are  crowded  together  in  classes  I  and  II,  scarcely 
anything  but  young  elements  are  available  for  the  defense  of  the  body,  cells 
with  slightly  indented  nuclei  are  heaped  togethei',  the  older  classes — III, 
IV,  and  V — are  practically  absent.     The  whole  course  of  the  case  agreed 


OBJECTIVE  SIGNS  291 

with  this  picture  with  almost  mathematical  accuracy,  and  with  each  new 
blood  count  a  further  deterioration  of  the  blood  picture  could  be  seen  until 
the  end.  All  these  important  changes  occur,  let  it  be  noted,  in  a  patient 
who,  according  to  former  views,  showed  a  leucopenia,  and  later  a  perfectly 
normal  number  of  leucocytes. 

Speaking  of  his  chronic  cases,  he  considers  that,  "  despite  a  good 
temperature  and  a  good  general  condition,  a  patient  who  shows  an 
abnormal  blood  picture  is  far  from  approaching  a  cure."  And  further: 
"  We  should  regard  those  cases  as  the  most  unfavorable  witli  the  most 
seriously  altered  blood  picture  and  with  a  normal  or  nearly  normal 
total  number  of  cells,  for  in  these  the  production  of  cells  barely  keeps 
pace  Avith  their  destruction,  and  is  not  able  to  surpass  it  and  produce 
a  leucocytosis.  .  .  .  We  are,  therefore,  justified  in  considering  an  in- 
crease in  the  total  number  of  white  cells  as  proguostically  favorable." 
(This  is  in  conflict  with  the  views  of  UUoni  and  Craig.) 

He  quotes  one  case  as  an  excellent  example  of  the  fact  that  a  normal 
blood  count  as  to  numbers  and  a  good  general  condition  cannot  be 
relied  on  if  the  blood  picture  is  abnormal.  In  this  case,  in  which  there 
were  9,100  cells — 51  in  Class  I,  -46  in  Class  II,  2  in  Class  III,  1  in 
Class  IV — the  patient,  on  account  of  his  very  sliglit  trouble,  had  already 
been  selected  from  among  the  cases  in  Leubo's  clinic,  from  which 
Arneth's  work  comes,  to  be  sent  to  a  sanatorium,  when  suddenly  he 
got  worse  with  fever,  severe  hemorrhages,  extension  of  the  local  process, 
and  rapid  deterioration  of  the  general  condition,  and  Arneth  considers 
the  case  excellent  evidence  of  the  point  he  wishes  to  make.  If  his 
claims  are  verified  by  further  study  of  other  observers,  we  would  evidently 
have  a  very  valuable  aid  in  the  fornmtion  of  a  prognosis,  and  it  is  to  be 
hoped  that  more  studies  will  be  made  in  this  direction.  I  have  now  used 
Arneth's  method  in  my  lal)oratory  for  some  time,  and  in  a1)0ut  100  cases, 
and  while  I  cannot  here  report  definitely  on  my  results,  I  can  say  that  on 
the  whole  I  have  found  them  to  correspond  closely  with  the  claims  of 
Arneth.  Cases  rapidly  losing  ground  have  uniformly  shown  a  rapid 
movement  to  the  left,  l)ad  cases  at  the  first  examination  have  always 
shown  a  marked  tendency  to  a  preponderance  of  classes  I,  II,  and  III, 
while  favorable  cases  Avith  good  vitality  have,  on  the  contrary,  almost 
always  shown  the  reverse. 

The  technic  is  not  difficult,  but  can  be  carried  out  by  any  careful  man 
used  to  differential  blood  counting,  and  I  am  inclined  to  belicA-e  that  it 
Avill  proA'e  a  valuable  method  of  estimating  the  resistance  of  a  ncAv  case 
or  of  anticipating  an  advance  of  the  process  as  j^et  not  determinable  by 
physical  examination. 

The  bacteriologic  study  of  the  blood  in  tuberculosis  has  hitherto 
produced  small  results.     The  bacillus  first  found  by  Weichselbaum  in 


292    SYMPTOMATOLOGY  OF  PULMONARY  TUBERCULOSIS 

post-mortem  blood  clots  in  acute  miliary  tuberculosis  was  first  discov- 
ered intra  vitam  by  his  pupil  Meisel,  and  it  has  since  been  demonstrated 
in  acute  cases  frequently  but  not  in  more  chronic  ones,  and  in  a  few 
cases  of  mixed  infection  streptococci  have  been  found  in  the  blood. 

The  chemistry  of  the  blood  has  been  studied  by  some,  and  Morac- 
zewski  ('03)  has  given  the  most  recent  complete  study  of  the  subject. 
The  alkalinity  is  markedly  decreased,  and  De  Eenzi  believes  that  this 
favors  the  growth  of  the  bacillus  in  the  body.  In  the  earlier  stages  the 
iron  content  is  increased,  though  later  decreased.  In  the  first  and  second 
stages  fibrin  is  increased,  but  decreased  in  the  third,  and  the  albumin 
content  of  the  blood  gradually  lessens  throughout  the  course. 

In  brief,  Moraczewski's  conclusions  are  that  there  is  a  decrease  of 
coloring  matter  and  of  iron,  a  loss  of  serum  albumin,  a  steady  decrease 
of  potassium  salts,  a  development  of  cellulose,  and  a  decrease  at  first, 
and  later  an  increase,  of  sodium  salts  and  chlorids. 

Metabolism. — The  metabolic  changes  in  pulmonary  tuberculosis  are 
marked,  as  would  be  expected  in  a  disease  in  which  wasting  is  so  promi- 
nent a  symptom,  and  numerous  observers  have  studied  them  carefully. 

A  comprehension  of  these  alterations  in  the  normal  metabolism  is  by 
no  means  of  purely  theoretic  or  scientific  interest,  but  is  important  to  a 
proper  understanding  of  the  disease,  and  especially  to  a  proper  management 
of  the  feeding  of  patients,  although,  unfortunately,  a  scientific  determina- 
tion of  a  patient's  nitrogenous  balance  is  only  possible  under  exceptional 
circumstances.  In  a  work  of  this  nature  the  metabolic  changes  can  only 
be  touched  on  in  their  most  important  aspects,  the  reader  who  is  inter- 
ested in  the  subject  being  referred  to  the  special  works  on  the  subject  (May, 
'03;  Winternitz,  '04). 

In  the  human  body,  in  health,  those  losses  of  weight  which  are  produced 
by  the  normal  tissue  waste  are  compensated  for,  and  the  proper  relation  of 
ingesta  to  excreta  (nutritive  balance)  is  maintained  by  a  proper  dietary 
and  by  a  normal  functioning  of  all  the  organs.  The  oxidation  of  food  pro- 
duces heat  and  energy  and  prevents  tissue  waste,  which  else  would  have  to 
occur  in  order  to  produce  them.  To  keep  up  this  constant  production  of 
heat  and  energy,  and  to  allow  of  the  building  up  of  new  tissue,  the  body 
must  have  supplied  to  it,  through  the  digestive  tract,  proteids  (nitrogenous 
substances),  fats,  and  carbohydrates,  not  to  mention  salts  and  water.  These 
substances,  according  to  Rubner's  law  of  calorific  equivalents,  or  isody- 
namia,  can  in  some  degree  substitute  each  other,  but  proteids  are  an  essen- 
tial element  and  cannot  be  substituted  by  either  fats  or  carbohydrates. 
The  necessary  amount  of  proteids  for  an  adult  workingman  is  118  gm. 
(483  cal.),  56  gm.  (520  cal.)  of  fats,  and  of  carbohydrates  500  gm.  (2,050 
cal.),  making  a  daily  requirement  of  about  3,000  calories  (Voit).^    If  the 

1  From  recent  researches  Chittenden  ('05)  believes  himself  justified  to  give  the 
standard  of  proteid  requirement  as  56  gm. 


OBJECTIVE   SIGNS  293 

food  is  not  sufficient,  the  deliciency  in  heat  must  be  supplied  by  the  body, 
chiefly  by  the  fat,  which  is  the  first  tissue  to  show  waste  in  denutrition. 
In  superalimentation,  on  the  contrary,  the  excess  of  fats  and  carbohydrates 
is  deposited  as  fat,  the  excess  of  albumin  being  decomposed,  the  nitrogenous 
part  being  excreted  as  urea,  while  the  nonnitrogenous  part  is  thrown  off  by 
the  respiration  as  CO2  and  H2O,  the  normal  albumin  content  of  the  body 
being  but  little  changed. 

Thus  the  nitrogen  excreted  in  the  urine  is  a  measure  of  the  albuminous 
destruction  of  the  body,  which  normally  equals  the  nitrogenous  intake, 
while  the  nitrogen  of  the  stools  gives  a  measure  of  the  nonabsorbed  nitro- 
gen. Thus  an  albuminous  gain  cannot  be  accomplished  by  an  excessive 
proteid  diet,  but  rather  by  the  use  of  a  diet  rich  in  albumin,  plus  ample  fat 
and  carbohydrates,  these  better  serving  to  economize  the  albumin  of  the 
body,  and  it  is  by  such  a  proper  mixed  diet  that  the  healthy  man  maintains 
a  fairly  constant  standard  of  weight. 

In  active  tuberculosis  there  is  always  an  excess  of  outgo  over  in- 
come, more  nitrogen  by  from  0.5  to  1  gm.  being  lost  daily  than  is  taken 
in,  in  average  cases,  while  in  severe  cases  of  caseous  pneumonia,  where 
the  waste  is  greatest,  from  the  extensive  cell  destruction  in  the  caseating 
areas,  it  can  go  as  high  as  12  gm.  (Huppert  and  Riesell,  '69).  It  is 
this  waste  which  is  compensatory  for  insufficient  intake  that  gave  the 
disease  the  name  of  consumption  or  phthisis. 

The  nutritive  balance  of  such  patients  is  upset.  They  suffer  con- 
stant loss  of  nitrogen  and  of  the  calories  necessary  to  carry  on  their 
economy,  or,  as  Grancher-Barbier  well  puts  it,  "  the  patient  is  constantly 
obliged  to  draw  on  his  resources  of  albumin  if  he  is  to  succeed  in  build- 
ing new  leucocytes  to  destroy  the  infective  agent  and  cicatrize  his  lesion." 

The  causes  of  this  wasting  are  several :  ( 1 )  poor  absorptive  power ; 
(2)  under-nourishment,  due  to  poor  appetite,  which  in  turn  is  due  to 
the  effect  of  the  poisons  of  the  germ  on  the  nervous  system,  producing 
lowered  nutrition  and  thus  favoring  extension  of  the  process;  (3)  in- 
creased tissue  waste  from  expectoration  and  sweats;  (-1)  effect  of  the 
toxins  on  the  cells  whose  vitality  and  regenerative  power  is  lessened 
thereby;  (5)  fever,  due  to  the  toxins. 

These  toxins  are  not  only  produced  ])y  the  living  germ,  but  are 
absorbed  in  large  amounts  from  the  necrotic  areas  into  which  they 
have  diffused  from  the  dead  bacilli,  this  being  the  explanation  of  the 
unusual  toxic  effect  in  caseous  pneumonia. 

In  periods  of  inactivity  of  the  disease,  the  nutritive  balance  is  prob- 
ably normal,  and  in  recovering  cases  the  clinician  has  evidence  of  its 
restoration  by  the  increasing  brightness  of  the  eye,  the  better  nourish- 
ment of  the  skin,  the  filling  out  of  hollows,  and  the  increased  snap  and 
vitality  which  arc  impossible  when  the  outgo  surpasses  the  income,  and 


294  SYMPTOMATOLOGY   OF  PULMONARY  TUBERCULOSIS 

while  gain  of  weight  is  n.ot  always  a  proof  of  a  restoration  of  iiutritive 
balance,  since  nitrogenous  waste  can  continue  even  Avhiie  fat  is  being 
deposited  (May,  '03),  this  is  not  common,  and  the  clinician  rightly 
regards  these  changes  as  the  best  possible  evidences  of  the  favorable 
progress  of  the  patient,  and  his  constant  effort  is  to  restore  the  balance 
of  the  economy  and  to  increase  the  patient's  weight  and  vitality.  Only 
thus  can  the  body  cells  be  vitalized  so  as  to  carry  on  their  fight  against 
the  invading  organism,  for  on  the  vitality  and  fighting  jwwer  of  the 
cells  entirely  depend  the  chance  of  contpiering  the  disease.  ' 

The  poor  absorj^tive  power  in  tuberculosis  "was  long  ago  noticed  by 
F.  Miiller.  In  two  cases  of  intestinal  tul)ereulosis  on  milk  diet,  and 
in  which  he  made  careful  estimations,  he  found  respectively  40.2  per 
cent  and  32.9  per  cent  of  fat  in  the  stools,  whereas  in  a  normal  man 
he  found  only  10  per  cent. 

This  poor  al)sorption  Winternitz  thinks  is  not  due  to  fever,  von 
Noorden  having  found  no  difference  in  the  al)sorptive  power  of  a  tuber- 
culous patient  during  a  prolonged  afebrile  period  and  during  a  period 
of  fever  produced  by  tubercidin,  while  Blumenfeld  and  Spirig  (*96) 
in  a  series  of  very  exact  determinations  found  the  absorption  of  both 
fat  and  lipanin  e.xeelk'nt  in  tulx'rculosis  without  intestinal  lesions. 
Therefore  the  lack  of  absorption  may  be  ascribed  to  the  intestinal  le- 
sions, but  it  should  be  remembered  that  frequently  the  physician  will  see 
early  cases  where  no  such  lesions  exist,  and  where  large  aiiu)unts  of  food 
are  taken,  and  yet  it  is  impossible  to  produce  any  gain  of  weight. 

The  amount  of  loss  from  sputum  and  sweats  is  prol)al)ly  not  great, 
except  in  advanced  cases,  where  they  are  very  profuse.  Lanz  in  IS 
cases  and  Ilenk  in  3  cases  found  a  loss  of  from  5  per  cent  to  6  per 
cent  of  the  total  nitrogen,  but  as  Ott  ('03)  notes  these  Avere  advanced 
cases,  and  only  in  such  he  thinks  coidd  the  sputum  be  a  material  source 
of  nitrogenous  loss.  The  solid  portion  of  the  sweats,  of  which,  accord- 
ing to  Argutinsky  ("90),  70  per  cent  is  urea,  an  end  product  of  albu- 
minous decomposition  can  deprive  the  liody  of  consideraljle  nitrogen, 
but  here  again  this  would  not  ordinarily  be  an  active  cause  of  loss. 

The  under-nourishment  produced  in  tuberculosis  by  the  anorexia  is 
an  active  source  of  wasting,  this  anorexia  being  considered  an  effect  of 
the  toxins  on  the  nerve  terminals.  Another  cause  of  tissue  Avaste,  but 
according  to  May  ('03)  not  a  marked  one,  is  cell  destruction  by  the 
toxins,  the  index  of  this  waste  being  the  amount  of  organic  phosphorus 
in  the  urine  (Grancher-BarJuer,  Mitulescu). 

A  marked  cause  is  the  fever  produced  by  the  absorption  of  toxins. 
Van  Noorden  found  that  a  nonfebrile  tuberculous  patient,  getting  a 
diet  which  furnished  43  calories  per  kilo,  made  slight  gains  in  his  nitrog- 
enous balance,  while,  after  a  period  of  fever  to  103°  F.  for  six  days. 


OBJECTIVE   SIGNS  295 

he  showed  a  nitrogenous  loss  varying  from  0.58  to  3.54  gm.  It  should 
be  noted,  however,  that  while  fever  produces  a  large  waste  of  albumin, 
its  effect  on  fat  is  slight,  loss  of  fat  being  chiefly  due  to  under-nourish- 
ment,  Avhile  in  late  cases  the  excess  of  muscular  action  produced  by  the 
dyspnea  and  chills  is  held  responsible  for  the  marked  fat  loss.  To 
recapitulate,  then,  the  chief  causes  of  nitrogenous  waste  in  tuberculosis 
are  under-nourishment,  the  effects  of  the  bacillary  toxins,  and  fever. 

The  excretion  of  mineral  substances  in  the  urine  in  tuberculosis  is 
an  index  of  the  cell  destruction  going  on  in  the  body,  this  having  been 
especially  emphasized  by  French  authors,  notably  IJobin  and  Binet  (01), 
who  speak  of  the  "  demineralization  "  of  the  system  in  this  disease  as 
an  early  occurrence  and  consider  it  of  great  value  in  diagnosis.  They 
consider  that  any  excess  of  excretion  of  these  bodies  beyond  the  point 
where  the  total  excretion  of  inorganic  bodies  is  to  the  total  dry  residue 
as  30  to  100  (coefficient  of  demineralization)  is  pathologic  and  can  be 
regarded  as  a  sign  of  incipient  tuberculosis.  Ott  ('02)  and  various 
German  authors,  however,  while  admitting  a  plus  of  excretion  in  ad- 
vanced cases,  deny  its  presence  in  early  cases,  and  consider  that  it  is 
due  not,  as  Robin  contends,  to  the  toxic  effects,  but  to  under-nourish- 
ment, and  points  out  that  the  French  results  rest  on  urinary  analyses 
alone  and  do  not  include  those  of  the  feces. 

The  phosphorus  compounds  are  abundant  in  the  body,  not  only  as 
calcium  phosphate  in  the  bones,  but  as  lecithin  and  nuclein  and  proteid 
combinations,  and  their  excretion  in  the  urine  the  French  consider  an 
evidence  of  increased  cell  destruction,  the  cells  being  the  carriers  of 
nuclein  and  lecithin,  which  in  turn  get  their  phosphorus  from  the  bones 
and  muscles,  and  the  excretion  of  phosphorus  the}^  believe  to  increase 
and  decrease  in  direct  relation  to  the  advance  and  retrogression  of  the 
process  in  the  lungs.  Mitulescu  ('03)  has  shown  that  where  a  negative 
nitrogenous  balance  exists,  the  excreted  phosphoric  acid  exceeds  the 
ingested  phosphorus,  the  inorganic  as  well  as  the  organic  phosphorus 
being  in  excess.  The  phosphoric  acid  is  chiefly  found  in  combination 
with  potash,  soda,  ammonia,  lime  and  magnesia,  and  one  third  of  it 
is  excreted  by  the  stools  as  calcium  and  magnesium  phosphate  and 
lecitiiin.  Ott  found  that  the  excretion  of  phosphorus  goes  parallel  with 
that  of  nitrogen. 

An  excess  of  lime  excretion  was  at  one  time  reported  by  Senator, 
but  his  results,  depending  only  on  an  analysis  of  the  urine,  have  been 
rejected  by  more  recent  writers.  Croftan  ('03)  found  an  increase  of 
calcium  excretion  in  the  urine  combined  with  deutero-allnimose,  and 
believing  that  there  is  an  affinity  of  this  latter  for  calcium,  and  since 
deutero-albumosc  is  found  in  calcifying  tuberculous  foci,  he  thinks  that 
the  use  of  calcium  salts  is  indicated  in  tuberculosis. 


296  SYMPTOMATOLOGY   OF  PULMONARY  TTTBERCULOSIS 

In  accordance  with  what  is  found  in  the  blood,  E.  Meyer  ('01),  in 
Gephardt's  clinic,  has  found  a  complete  reversal  of  the  relation  of  the 
potassium  and  sodium  excretion.  Normally  this  relation  is  1  gm.  of 
potassium  to  2  or  3.5  gm.  of  sodium,  but  in  advanced  phthisis  he 
found  the  relation  to  be  3  gm.  of  K  to  1  gm.  of  Na,  although  in  early 
cases  he  found  the  relation  normal.  This  he  ascribes  to  the  increased 
destruction  of  albumin  in  the  tissues,  especially  the  muscles. 

Aside  from  the  loss  of  nitrogen  and  mineral  substances,  tuberculous 
patients,  with  much  intestinal  trouble  or  with  large  purulent  cavities, 
lose  considerable  amounts  of  indican  through  the  urine.  Albumoses 
are  found  in  the  urine  chiefly  in  cavity  cases  and  as  the  result  of  fever 
(Krehl  and  Matthes,  '95).  Acetone  and  diacetic  acid  is  also  found  in 
old  cases  with  much  tissue  destruction,  according  to  Winternitz,  but 
this  is  denied  by  Ott.  Amyloid  and  fatty  degeneration  are  the  evidences 
of  the  deposit  in  the  body  of  tissue  waste.  Hoppe-Seyler  ('91)  found 
an  increase  of  urobilin  after  injections  of  tuberculin,  and  concludes 
from  this  that  the  toxins  have  the  power  to  destroy  red  cells. 

The  gaseous  metabolism  in  tuberculosis  is  but  slightly,  if  at  all,  al- 
tered, the  system  accommodating  itself  to  the  lessened  lung  area,  and,  as 
is  usual  in  the  body,  accomplishing  the  same  amount  of  work  with  the  de- 
creased amount  of  tissue.  The  earlier  experiments  seemed  to  demonstrate 
a  decreased  COg  excretion,  but  later  and  much  more  accurate  work  by 
Moeller  in  Pettenkofer's  clinic  by  A.  Loewy  ('91)  and  by  Kraus  and 
Chvostek  ('91)  have  shown  this  last  to  have  been  incorrect.  A  mod- 
erate increase  of  oxygen  intake  and  CO,  excretion  was  found  by  these 
observers,  but  not  to  the  extent  taught  by  Kobin  and  Binet  ("01). 
These  latter  claimed  a  marked  increase  of  respiratory  exchange  in  tuber- 
culosis in  92  per  cent  of  their  392  cases,  and  they  consider  this  an 
inherited  tendency  in  those  susceptible  to  the  disease,  and  contrast  it 
with  the  decreased  exchange  in  gout  and  rheumatism.  Loewy  consid- 
ers that  an  increase  of  oxygen  intake  and  CO,  excretion  is  evidence  of 
an  increased  destruction  of  albumin  but  not  of  fat. 

Winternitz,  going  over  the  same  ground  as  Robin  and  Binet  in 
afebrile  cases,  comes  to  the  conclusion  that  cases  of  chronic  afebrile 
tuberculosis  have  an  oxygen  consumption  which,  while  within  the  limits 
of  the  normal,  is  somewhat  high  if  the  patient  is  emaciated  or  if  there 
is  much  destruction  of  tissue,  but  if  the  nourishment  is  good,  even  if 
the  process  be  advanced,  it  is  strictly  normal,  and  he  considers  that  a 
plus  of  oxygen  consumption  in  advanced  cases  is  due  to  emaciation 
and  to  the  increase  of  respiratory  action,  he  having  found  the  oxygen 
consumption  proportionate  to  the  degree  of  emaciation. 


CHAPTER   II 
PHYSICAL    EXAMINATION 

By   CHARLES   L.    MINOR 

Physical  Examination. — In  the  examination  of  an  incipient  case  of 
puhnonarv  tuberculosis  the  most  careful,  thorough,  painstaking  work 
is  demanded,  and  the  frequent  failure  to  diagnose  the  disease  in  its 
beginning  is  due  chiefly  to  a  lack  of  sufficient  time  and  care  in  the 
examination.  Physicians,  accustomed  chiefly  to  seeing  acute  diseases, 
do  not  always  realize  that  the  slight  changes  existing  in  early  tuber- 
culosis can  produce  at  most  only  slight  alterations  from  the  normal, 
which  can  easily  be  overlooked  unless  an  amount  of  time  and  pains  be 
given  to  the  examination  which  is  not  always  necessary  in  more  acute 
troubles.  While  a  few  great  diagnostic  experts,  like  the  celebrated 
Oppolzer,  of  Vienna,  can  make  a  diagnosis  in  some  cases  with  a  glance 
and  a  touch,  quickly  and  yet  surely,  such  men  will  always  be  the  excep- 
tions, and,  as  a  rule,  it  is  safe  to  say  that  good  work  cannot  he  done 
in  a  hurry  or  without  proper  equipment  and  surroundings,  and  thus 
he  who  gives  himself  time  and  the  right  conditions,  and  follows  a 
carefully  determined  routine  in  his  work,  wall  make  correct  diagnoses 
in  many  cases  where  the  less  painstaking  will  fail,  and  will  discover 
small  foci  of  trouble  which  else  would  be  entirely  overlooked. 

Equipment  of  Examining  Eoom. — The  proper  equipment  of  the 
examining  room  is  a  matter  of  real  importance,  and  the  physician  will 
save  time  and  increase  the  accuracy  of  his  work  by  seeing  to  it  that 
he  has  all  the  necessary  apparatus  close  at  hand,  and  so  conveniently 
and  systematically  arranged  that  it  can  be  used  quickly  and  easily.  This 
is  the  secret  of  the  excellent  diagnostic  work  done  in  large  hospitals, 
infinite  pains  and  proper  equipment  being  used  systematically;  by  re- 
producing these  conditions  the  private  practitioner  can  reproduce  the 
results.  Too  commonly  the  physician  has  nothing  ready;  he  must  hunt 
up  a  stethoscope  and  tape,  has  no  skin  pencil  at  hand,  no  special  table 
and  examining  stool,  and  has  to  use  whatever  comes  handy. 

Thus,  following  no  set  routine,  and  often  not  recording  his  results 
on  a  systematic  form,  he  places  perfectly  needless  handicaps  on  his 
nervous  efficiency,  decreases  proportionately  his  powers  of  observation, 
21  297 


298  PHYSICAL   EXAMINATION 

and,  moreover,  keeps  no  proper  record  for  future  reference.  The  exam- 
iner's mind  should  be  entirely  free  to  concentrate  itself  with  intense 
earnestness  on  the  problem  before  it,  undisturbed  by  anything,  and  his 
body  should  be  so  relaxed  and  at  rest  as  not  to  hamper  him  in  the  least. 
Few  realize  that  for  the  most  complete  use  of  any  faculty  one  must 
be  entirel}^  undisturbed  not  merely  by  outside  noises,  etc.,  but  by  strained 
positions  or  tense  muscles,  and  that  by  avoiding  these  handicaps  the 
keenness  of  hearing,  sight,  and  touch  can  be  greatly  increased. 

The  Room. — The  room  should  be  quiet  and  as  free  from  outside 
noises  and  disturbances  or  interruptions  as  possible.  It  should  have,  if 
feasible,  northern  light  through  large  windows,  and  since  the  patient 
must  be  stripped  to  the  waist  it  must  be  heated  easily  and  rather  more 
than  comfortably  warm — about  75°  F.  There  should  be  a  special 
table  kept  solely  for  the  examination,  and  on  which  all  needed  instru- 
ments are  conveniently  arranged  with  a  place  for  everything  and  every- 
thing in  its  place,  and  the  writer  has  found  the  common  glass-topped, 
glass-shelved,  enameled  iron  ward  table  very  good  for  this  purpose. 
On  it  should  be  placed  the  regular  stethoscope  and  any  modified  forms 
that  we  may  wish  to  use  for  special  cases,  such  as  the  phonendoscope  or 
Bowles's  stethoscope.  There  should  also  be  a  steel  tape  measure,  a 
leather-covered  lead  tape,  a  pair  of  chest  calipers,  a  skin  pencil,  colored 
pencils  for  recording  findings,  and  a  spatula  and  a  jar  of  cold-cream 
vaselin  to  anoint  dry,  harsh,  or  hairy  skins.  Fixed  on  the  table 
should  be  a  paper  clip  to  hold  the  examining  chart  steady,  so  that  find- 
ings can  be  recorded  easily. 

Beside  the  table,  with  its  back  to  the  window,  should  be  the  physi- 
cian's examining  chair,  the  common  laryngologist's  chair  with  springy 
back  being  the  best  for  this  purpose.  Facing  this  chair  shoidd  be  a 
stool  for  the  patient,  and  I  consider  it  a  detail  of  real  importance  that 
this  should  be  a  rotating  one,  the  ability  to  spin  the  patient  around 
quickly  to  get  at  any  part  of  the  chest  saving  much  time  and  often 
avoiding  the  use  of  .strained  attitudes.  In  order  to  be  able  to  map  out 
the  stomach  or  to  study  Litten's  diaphragmatic  phenomenon  a  sofa  is 
necessary.  In  addition,  a  height  measure,  permanently  fastened  to  the 
wall,  a  reliable  scale,  and  a  wet  spirometer  are  necessary. 

Barring  the  laryngoscopic  and  Eoentgen-ray  outfits,  this  completes 
a  list  of  all  the  essentials,  and  they  are  easily  had  and  very  cheap,  so 
that  no  one  who  does  any  chest  examining  need  be  deprived  of  the 
great  assistance  they  offer.  The  necessary  equipment  for  a  laryngeal, 
oral,  and  nasal  examination  (an  aural  examination  is  rarely  needed) 
should  be  regarded  as  essential,  and  it  is  time  the  profession  realized 
that  no  pulmonary  examination  can  be  said  to  be  complete  unless  we 
know  the  condition  of  these  vestibules  of  the  lungs. 


PHYSICAL   EXAMINATION  299 

While  a  Roentgen-ra}'  equipment  is  not  esi^ential,  it  is  of  ver}'  great 
value.  If  the  Roentgen-ra}^  is  used  the  room  must  be  made  a])Solutely 
dark,  and  it  is  better  to  have  for  this  purpose,  and  for  the  laryngeal 
examination,  a  special  room  with  walls  colored  a  dark  red  and  with 
windows  and  doors  so  adjusted  as  to  exclude  the  smallest  ray  of  light. 

Time  of  Examixatiox. — This  will  usually,  of  necessit}',  be  largely 
determined  by  the  arrangement  of  the  physician's  day.  However,  in 
incipient  cases  where  the  detection  of  a  few  fine,  isolated  rales  may  be 
of  great  importance,  the  time  immediately  after  waking,  when  there  is 
most  secretion  in  the  lungs,  is  unquestionably  the  best  time  for  exami- 
nations, as  at  such  times  one  can  hear  rales  which  are  entirely  inaudible 
during  the  rest  of  the  day.  Such  a  time,  however,  for  the  full  exami- 
nation is  not  usually  feasible  except  in  special  cases,  in  which  case  we 
should  make  a  special  visit  to  the  patient's  house  early  in  the  morning 
for  this  purpose. 

The  doctor  should  not  undertake  such  examinations  during  his  regu- 
lar office  hours  while  he  is  subject  to  many  and  constant  interruptions, 
making  concentrated  consecutive  thought  impossible,  and  when  the  con- 
sciousness that  other  patients  are  impatiently  waiting  to  see  him  is 
apt  to  tempt  him  to  hurry  through  his  work.  He  should,  therefore, 
especially  if  he  devotes  himself  particularly  to  such  work,  have  an  espe- 
cial time  of  the  day  to  make  such  examinations  by  appointment,  when 
nothing  will  interrupt  him  and  when  he  can  concentrate  himself  on  the 
work  in  hand. 

The  time  necessary  for  a  thorough  examination  varies  considerably 
with  the  difficulties  of  the  case  and  with  the  physician.  A  first  exami- 
nation, including  a  painstaking  history,  a  laryngeal,  fluoroscopic,  and 
physical  examination,  demands  at  the  very  least  one  hour,  often  much 
more.  Eeexaminations  can  be  completed  usually  in  from  half  an  hour 
to  forty-five  minutes.  Frequent  reexaminations  are  unnecessary  and 
undesiral)le  in  tuberculosis,  and  the  usual  custom  of  monthly  examina- 
tions, with  such  brief  studies  of  the  auscultatory  findings  in  between 
as  the  developments  of  the  case  may  demand,  is  ample,  and  chronic 
favoral)le  cases  with  which  we  are  thoroughly  familiar  can  at  times  go 
two  or  three  months  without  examinations,  the  changes  in  such  cases 
being  too  gradual  to  render  more  frequent  examinations  of  value.  On 
the  other  hand,  in  active,  acute,  advancing  cases  the  chest  may  need  to 
be  watched  two  or  three  times  a  week. 

In  setting  a  time  for  an  examination,  the  menstrual  period  should 
be  avoided  in  women,  and  routine  examinations  should  not,  if  possible, 
be  made  in  cases  where  the  temperature  is  over  101°  F.  or  during  acute 
congestions,  or  even  slight  colds.  Except  in  the  case  of  patients  who 
are  too  sick  to  leave  the  house,  all  regular  examinations  should  be  made 


300  PHYSICAL  EXAMINATION 

at  the  office,  where  the  physician  has  at  hand  every  convenience,  and 
where  much  better  work  can  be  done  than  at  the  patient's  house. 

History. — Aside  from  the  great  importance  for  a  correct  diagnosis 
of  a  carefully  taken  and  recorded  history  of  the  patient,  a  step  that 
should  be  the  beginning  of  every  examination,  the  time  thus  occupied 
allows  a  patient  to  get  over  some  of  his  natural  excitement  and  to  quiet 
down,  and  a  tactful  physician  will  take  occasion  to  lay  the  foundations 
of  relations  of  confidence  with  his  patients  at  this  time.  Most,  if  not 
all,  patients  come  to  the  office  greatly  excited,  apprehensive,  and  Avrought 
up,  and  this  should,  as  far  as  possible,  be  allayed  before  beginning  the 
physical  examination.  The  presence  of  relatives  and  friends  during  the 
history  taking,  Avhile  at  times  adding  useful  facts  to  the  history,  often 
causes  a  patient  to  withhold  valualjle  information  as  to  his  past  life  which, 
if  alone,  he  will  confide,  and  thus  histories  of  past  dissipations,  syphilis, 
love  affairs,  family  troubles,  etc.,  which  bear  on  the  cases  are  missed. 
At  the  same  time,  relatives,  especially  wives  or  mothers,  can  often  sup- 
ply facts  as  to  the  patient's  personality,  past  life,  sickness,  and  family 
history,  better  than  he,  so  that  it  is  wise,  after  having  taken  the  history 
with  the  patient  alone,  to  have  the  relative  come  in  and  add  any  infor- 
mation possible. 

A  regular  routine  in  the  history  taking  should  be  followed  to  get 
histories  systematic  enough  to  be  of  value  for  reference,  and  while 
printed  history  forms  are  a  great  inconvenience  by  limiting  one  to  a 
fixed  space  in  every  case,  they  are  valuable  since  they  prevent  us  from 
forgetting  any  of  the  many  details  to  which  we  should  turn  our 
attention. 

The  recording  of  histories  in  bound  volumes  is  a  great  mistake  if 
we  ever  expect  to  use  them  for  reference,  the  card  index,  using  large 
sheets  of  very  thin  cardboard,  being  infinitely  preferable.  In  private 
practice,  no  less  than  in  sanatoria,  facts  as  to  birthplace,  previous  resi- 
dences, various  occupations,  age,  sex,  condition,  permanent  address, 
should  always  be  included  if  we  hope  ever  to  be  able  to  follow  up  the 
future  history  of  our  cases. 

The  family  history  must  be  taken  carefully  if  it  is  to  be  of  any 
value.  The  general  statement,  so  popular  with  patients  when  speaking 
of  the  health  of  their  families,  such  as  "  all  my  family  have  been  per- 
fectly healthy,"  "  none  of  my  people  have  had  Ivmg  trouble,"  etc., 
should  never  be  accepted,  but  the  health,  age,  cause  of  death  of  the 
paternal  and  maternal  grandfathers,  grandmothers,  uncles,  aunts,  and 
first  cousins,  and  of  the  father,  mother,  brothers,  and  sisters,  should 
be  inquired  into  individually.  We  should  also  investigate  the  possible 
existence  on  the  paternal  or  maternal  side  of  any  marked  tendency  to 
dyspepsia,  nervousness,  anemia,  or  weak  lungs.    In  this  way  we  will  often 


PHYSICAL  EXAMINATION  301 

discover  cases  of  probable  tuberculosis  in  the  families  of  patients  who 
have  asserted  that  their  family  was  entirely  healthy,  or  it  may  reveal 
a  tendency  to  gout  and  rheumatism  which  has  a  distinctly  favorable 
prognostic  value. 

The  rest  of  the  history  is  best  divided  into  sections  on  "  Childhood 
History,"  one  on  "  Past  Life  and  Sicknesses,"  one  on  "  Habits,"  one 
on  "  Present  Sickness,"  and  a  statement  as  to  the  "  Status  Prsesens," 
or  existing  conditions,  at  the  time  of  examination. 

The  childhood  history  in  women  ends  at  the  beginning  of  the  female 
life,  and  in  men  the  writer  has  found  it  practical  to  have  it  end  at 
the  time  of  going  to  college  or  into  business.  The  condition  of  the 
home  during  childhood,  as  to  its  sanitary  conditions,  ought  to  be  noted, 
as  well  as  possible  exposures  to  infections  from  sick  relatives  or  others. 
Any  exanthemata,  especially  measles,  attacks  of  pertussis,  pneumonia, 
pleurisy,  bronchitis  or  tonsillitis,  any  enlarged  cervical  glands,  otorrhea, 
and  the  childhood's  habit  of  appetite  and  digestion — all  are  of  value. 
The  conditions  of  school  or  college  life  must  always  be  investigated — the 
health  of  roommates,  the  ventilation  of  rooms,  and  the  quality  of  the 
food  all  giving  valuable  information. 

The  past  life  and  sicknesses  should  include  the  life  from  childhood 
up  to  the  present  trouble,  and  should  bring  out  information  as  to  the 
hygienic  conditions  of  the  houses  lived  in,  and  of  the  various  occupa- 
tions, possibilities  of  infection,  marriage,  and  the  health  of  wife  and 
children,  and  all  past  sicknesses. 

Habits  is  an  important  heading  often  omitted.  From  it  we  should 
try  to  get  some  idea  of  the  exact  mode  of  life  and  method  of  spending 
the  time.  The  hours  of  work  and  the  methods  of  work,  the  tempera- 
ment and  mental  attitude,  the  average  weight  and  best  weight,  appetite, 
digestion,  sleep,  and  nerves,  and  any  undue  tendencies  to  catching  cold, 
should  all  be  noted,  as  well  as  past  histories  of  malaria,  neurasthenia, 
dyspepsia,  pleurisies,  etc.,  which  without  questioning  the  patient  will 
often  forget,  and  which  can  give  a  possible  hint  as  to  the  commence- 
ment of  the  trouble.  The  information  given  under  this  head  gives  some 
idea  of  the  life  and  personality  of  patients. 

The  Present  Sickness. — The  first  question  here,  if  we  wish  to 
find  the  real  beginning  of  the  trouble,  should  be  not  "  When  did  your 
sickness  begin,"  but  "  When  were  you  last  perfectly  well  ?  "  for  most 
patients  have  had  a  more  or  less  extensive  period  of  imperfect  health 
before  the  development  of  symptoms  sufficiently  active  to  draw  their 
attention  to  them,  and  by  inquiring  in  this  way  we  get  a  much  earlier 
date  for  the  beginning  of  the  trouble  than  the  patient  would  otherwise 
report.  The  average  patient,  when  asked  how  long  he  has  been  sick, 
will  usually  date  it  back   to  the  cough,   cold,   grip,  hemoptysis,   etc., 


302  PHYSICAL  EXAMINATION 

that  to  him  seemed  to  hegin  his  sickness,  whereas  to  the  doctor  it  may- 
date  back  from  months  to  years  before  the  present  trouble,  and  may  be 
separated  from  it  by  quite  a  period  of  good  health.  At  such  times  a 
patient  will  generally  report  he  was  pale,  somewhat  off  in  weight, 
strength,  or  appetite,  had  a  slight  clearing  of  his  throat,  but  with  a 
little  care  he  got  over  these  symptoms  and  forgot  them. 

With  these  data  and  facts  determined  the  patient  should  then  be 
urged  to  give  his  own  account  of  his  trouble,  only  omitting,  as  far  as 
.Ave  can  induce  him  to  do  so,  the  many  utterly  irrelevant  family  details 
he  usually  wishes  to  mention.  After  this  a  few  questions  will  make 
clear  the  course  and  development  of  the  disease. 

Finally,  the  Status  Prccscns,  or  actual  condition  at  the  time  of  ex- 
amination, should  be  recorded  for  future  comparison.  We  should  note 
the  amount  of  cough  and  expectoration,  and  the  presence  or  al)sence 
of  fever,  sweats,  chills,  dyspnea,  hoarseness,  dysphagia,  pallor,  blood- 
spitting,  the  condition  of  the  appetite,  digestion,  bowels,  sleep,  nervous 
system,  the  mental  attitude,  and  the  weight.  A  history  so  taken  is  in- 
valuable for  future  reference  or  for  scientific  study. 

The  Exajiixation. — If  this  is  to  yield  the  maximum  of  infor- 
mation, it  must  be  carried  out  systematically,  according  to  a  logical 
plan,  and  to  assure  this  the  physician  should  have  a  well-designed  chart 
whose  routine  he  can  follow  in  every  case,  and  on  which  he  records  his 
findings.  Only  thus  can  even  the  most  careful  man  avoid  the  omission 
of  certain  points  and  get  records  which  are  complete  and  of  value  for 
future  study.  The  writer  believes  that  each  physician  can  do  best,  after 
consulting  good  standards,  to  plan  his  own  chart,  the  cuts  for  which 
he  can  get  from  numerous  books  of  reference  and  which  can  be  made 
cheajjl}^  by  almost  any  printing  house  in  electroplate,  and  which  can  be 
printed  for  him  under  his  own  eye.  Such  a  chart  will  probably  be  more 
usefid  to  him  than  anything  he  can  buy  ready  made.  It  must  not  be 
so  small  as  to  be  crowded  and  awkward  for  reference,  and  should  be  of 
such  a  size  that  when  folded  once  it  will  match  the  size  of  his  history 
chart  and  be  filed  away  with  it. 

There  should  be  printed  matter  for  recording  the  findings  on  inspec- 
tion, palpation,  and  mensuration,  as  well  as  graphic  outlines  for  record- 
ing the  laryngologic  findings.  The  Eoentgen-ray,  percussion,  and  aus- 
cultation findings  should  be  recorded  on  three  sets  of  outline  pictures 
of  the  thorax  from  the  front  and  from  behind,  but  there  should  also 
be  a  place  for  writing  a  verbal  description  to  supplement  the  graphic 
record,  where  that  is  necessary,  since,  whereas  the  graphic  record  is 
usually  more  valuable  than  a  written  one,  there  are  times  when  only 
a  written  one  can  properly  describe  certain  conditions. 

It  is  best  to  begin  the  examination  by  taking  the  patient's  weight 


PHYSICAL   EXAMINATION  303 

and  height.  Since  we  will  usually  have  no  opportunity  to  weigh  patients 
naked,  and  since  the  weight  of  the  usual  clothing  is  fairly  fixed,  it  is 
distinctly  better  to  weigh  the  patient  in  his  clothes.  The  height  is  taken 
in  his  shoes,  from  Avhich  subtract  the  height  of  his  heels,  which  should 
always  be  measured,  so  as  to  get  figures  for  the  height  that  can  be  used 
in  estimating  the  normal  capacity  and  chest  circumference,  and  the 
corpulence  if  this  is  desired.  Since  the  vital  capacity  necessitates  very 
deep  breathing,  it  should  best  be  postponed  until  the  end  of  the  exami- 
nation. 

.  Xext  in  order  should  come  the  laryngeal,  oral,  and  nasal  examina- 
tions, and  if  there  are  any  ear  symptoms,  an  aural  examination.  Un- 
fortunately, many  physicians  doubt  their  skill  in  laryngoscopy  or  rhi- 
noscopy, and  either  omit  this  important  step  entirely,  or,  if  marked 
laryngeal  symptoms  exist,  send  the  patient  to  the  laryngologist ;  but 
since  a  report  from  another  as  to  existing  conditions  is  of  distinctly 
less  value  in  the  impression  it  produces  on  the  mind  than  is  the 
impression  gotten  Ijy  the  use  of  our  own  eyes,  this  is  much  to  be  re- 
gretted. The  information  to  be  gained  both  for  diagnosis  and  prog- 
nosis is  of  such  value  that  every  physician  should  master  the  simple 
technic,  and  this  anyone  who  is  willing  to  take  a  little  trouble  can  do. 
When  once  this  technic  is  mastered,  a  3'ear  or  so  of  careful  study  of 
the  larynx  in  every  patient,  with  the  use  of  a  well-illustrated  atlas  of 
larjTigoscopy,  such  as  that  of  Krieg  or  of  Grunwald,  will  enable  him 
to  recognize  abnormal  conditions  and  acquire  suflficient  diagnostic  skill 
to  greatly  assist  him  in  the  study  of  his  cases,  while  difficult  or  puzzling 
ones  can  still  he  referred  to  the  specialist  for  final  judgment. 

Inspection  of  the  mouth  often  gives  a  hint  of  syphilis;  the  condition 
of  the  teeth  and  gums  can  throw  light  on  the  causation  of  digestive 
troubles;  unduly  abundant  adenoid  tissue  in  the  pharynx  or  enlarged 
tonsils  give  information  as  to  the  patient's  constitution;  while  the  dis- 
covery of  an  enlarged  lingual  tonsil,  pressing  on  the  epiglottis,  will 
often  clear  up  the  causation  of  an  oI)stinate.  inexplicable  cough. 

An  examination  of  the  nose  very  often  demonstrates  an  hypertrophy 
of  one  of  the  turbinates,  the  presence  of  polypi,  a  deflection  or  spur 
of  the  septum,  resulting  in  obstruction  to  the  free  access  of  air  to  the 
lungs  in  nasal  breathing,  and  gives  a  valuable  therapeutic  hint,  the 
removal  of  such  occlusions  in  these  cases  often  having  remarkably  bene- 
ficial effects.  Perforations  of  the  septum  will  at  times  be  found,  and 
will  explain  abnormal  breath  sounds  which  this  condition  can  produce. 
Posterior  rhinoscopy  is  difficult  to  any  but  the  specialist,  but  can  be 
very  useful  in  revealing  adenoids.  Lar}Tigoscopy  reveals  some  lar}Tigeal 
abnormality  (see  Laryngeal  Symptoms)  in  a  large  number  of  cases, 
and  should  under  no  circumstances  be  omitted. 


304  PHYSICAL  EXAMINATION 

The  nose  and  throat  examination  being  completed,  and  they  need 
take  but  a  very  short  time  when  once  a  physician  is  familiar  with  their 
technic  and  has  acquired  a  familiarity  with  the  normal  and  abnormal 
conditions,  the  patient  should  he  requested  to  undress  to  the  waist.  In 
these  days  of  accurate  work  it  should  not  be  necessary  to  insist  on  the 
absolute  necessity  of  examining  directly  on  the  skin  if  we  hope  to  get 
reliable  results,  but,  though  our  German  confreres  have  for  years  taught 
this,  the  American  profession,  especially  when  examining  women,  still 
very  commonly  neglect  it,  and  I  have  heard  good  men  maintain  that 
they  could  listen  as  well  through  clothing  as  not.  The  latter  statement 
is  too  diametrically  opposed  to  the  results  of  the  best  clinical  experience 
to  need  refutation,  and  the  claim  that  we  will  shock  a  patient's  modesty 
is  equally  unsupportable. 

The  writer  has  for  many  years  examined  all  patients  stripped  to  the 
waist,  the  patients  coming  largely  from  the  more  refined  walks  of  life, 
and  he  has  yet  to  find  any  expressed  objection  to  this  most  necessary 
step  by  any  women  except,  strange  to  say,  by  a  few  who  alone  of  all 
the  number  had  no  right  to  modesty  at  all,  but  in  such  women  we  do 
frequently  find  an  appalling  excess  of  modesty,  which  is  most  amusing. 
Doubtless,  if  the  doctor  hems  and  haws  and  seems  embarrassed  at  ask- 
ing the  patient  to  undress,  and  does  not  go  out  of  the  room  to  give  her 
an  opportunity  to  do  so,  he  would  suggest  to  her  the  very  feelings  that 
he  fears  she  may  have,  but  if  he  goes  about  it  directly  and  as  a  matter 
of  course,  he  will  find  no  trouble  at  all. 

There  should  always  be  a  light  flannel  shawl  at  hand  to  tlirow 
around  the  patient  between  the  various  steps  of  the  examination,  but 
none  will  object  to  its  removal  during  the  examination.  Some  patients 
are  unduly  afraid  of  catching  cold,  and  having  such  a  wrap  handy  re- 
assures them,  but,  since  we  examine  in  an  imduly  warm  room,  this  is 
a  matter  of  imagination  rather  than  fact,  and  the  writer  has  seldom 
seen  patients  catch  cold. 

As  to  whether  the  Eoentgen-ray  examination  should  precede  or  fol- 
low the  physical  examination,  is  a  question  that  will  be  differently  set- 
tled, according  as  to  whether  the  physician  considers  the  one  or  the 
other  the  more  reliable. 

Personally,  considering  the  Eoentgen-ray  as  of  inferior  accuracy  to 
the  physical  examination,  the  writer  puts  fluoroscopy  first,  so  as  not 
to  find  himself  prepared  to  detect  by  it  evidences  of  the  lesions 
discovered  by  auscultation  and  percussion.  After  the  Eoentgen-ray 
examination,  look  for  the  physical  signs  which  its  findings  have 
suggested.  This  is  wiser  than  to  reverse  the  procedure,  for  physical 
signs  are  of  more  value  in  forming  an  opinion  than  Eoentgen-ray 
shadows.     However,  a  description  of  the  steps  of  the  Eoentgen-ray  ex- 


PHYSICAL   EXAMINATION  305 

amination  will  be  given  later  as  being  a  newer  and  less  important 
procedure. 

The  patient  ma}^  assume  either  the  standing,  sitting,  or  lying-do^\Ti 
position.  Very  sick  patients  must,  of  course,  be  examined  lying  down 
in  their  beds,  but  any  patients  who  are  al)le  to  come  to  the  office  should 
be  examined  in  the  upright  posture,  unless  the  recumbent  position  is 
indicated  for  special  reasons,  such  as  in  a  search  for  rales  or  in  study- 
ing Litten's  phenomenon  or  for  an  examination  of  the  abdomen.  While 
some  physicians  prefer  to  examine  the  patient  standing,  this  is  not  de- 
sirable, as  both  the  patient  and  the  physician  are  thereby  placed  under 
more  or  less  of  a  strain,  and  in  nearly  every  ease  the  sitting  posture  will 
be  found  the  most  satisfactory. 

Inspection. — The  room  being  properly  warmed  and  the  patient 
stripped  to  the  waist,  one  proceeds  to  the  inspection.  For  this  step  espe- 
cially, which  calls  for  the  closest  powers  of  observation  on  the  physician's 
part,  the  patient  should  be  seated  stripped  to  the  waist  directly  facing 
the  window,  best  in  diffuse  bright  da3light  with  each  side  equally  illu- 
minated. When  first  he  seats  himself,  the  patient  should  be  allowed  to  take 
his  natural  posture,  for  in  this  way  one  will  often  get  an  excellent  idea  of 
habitual  faults  of  position  which  call  for  correction.  After  this  the  patient 
should  be  made  to  sit  erect,  but  not  "  strutting,"  in  an  easy  upright  pose. 

First  one  notices  the  position  and  prominence  of  the  clavicles  and 
the  condition  of  the  supraclavicular  and  infraclavicular  fossae,  the  ster- 
num, then  the  remainder  of  the  anterior  thorax  should  be  observed  for 
abnormalities.  Slight  flattening  of  the  shoulder  outline  or  shoulder 
droop  must  also  be  looked  for,  and  the  general  build  and  form  of  the 
thorax,  its  length,  breadth,  and  the  angle  of  the  ribs  and  breadth  of 
the  intercostal  spaces  noted.  Posteriorly,  one  notes  the  position,  height, 
and  motion  of  the  scapulae,  the  fullness  or  flattening  of  the  supraspinous 
muscles,  and  any  possible  scolioses  or  other  spinal  deformities.  Then 
follows  inspection  for  alterations  of  motion.  This  is  done  in  two  ways: 
First,  facing  the  patient's  front  or  back,  and  noting  the  relative  upward 
motion  on  deep  inspiration  of  the  ribs  and  shoulders;  then,  standing 
behind  the  patient  and  looking  down  the  anterior  chest  wall,  observe 
the  lifting  of  the  ribs,  outward  and  upward,  and  in  this  way  one  can 
note  very  slight  differences  of  motion  between  the  two  sides. 

Too  hasty  and  cursory  inspection  is  condemnable.  Inspection  is  a 
valuable  but  a  very  delicate  method,  and  one  should  observe  very  closely 
and  carefully  in  order  to  profit  fully  from  this  procedure.  In  addition 
to  inspection  of  the  chest,  note  the  patient's  general  build  and  nourish- 
ment, the  condition  of  the  skin  and  complexion,  the  condition  of  the 
pupils,  hair,  finger  tips,  nails,  teeth,  and  gums,  as  well  as  the  tongue  and 
any  existing  dyspnea. 


306  PHYSICAL  EXAMINATION 

Palpation. — Palpation  of  the  apical  regions  and  of  the  first  and 
second  interspaces  is  hest  performed  with  the  ulnar  border  of  the  hand, 
below  that  level  applying  the  four  fingers,  evenly  but  not  too  firmly 
is  better.  Goldscheider  ('07)  recently  recommended  for  orientation 
previous  to  his  percussory  determination  of  the  absolute  height  of  the 
apex  the  deep  palpation  between  the  heads  of  the  sternocleidomastoid 
of  the  tubercle  of  the  first  ril),  which  is  in  definite  relation  to  the  apex. 
The  writer  has  found  this  feasible  in  thin  subjects,  as  well  as  in  the 
determination  of  the  inner  border  of  the  first  rib,  but  the  procedure 
is  painful  to  the  patient,  as  Goldscheider  admits,  and  the  information 
gained  is  not  indispensable.  While  palpating,  one  should  be  sure  to 
examine  the  neck  for  possible  enlarged  cervical  glands,  and  the  pulse 
for  its  tension. 

As  noted  under  "  Blood-Pressure,"  finger  estimations  of  tension  are 
uniformly  lower  than  would  be  expected  from  the  readings  such  pulses 
give  with  the  sphygmomanometer.  Estimation  of  the  pulse-rate  during 
an  examination  is  usually  worthless,  the  patient  being  too  excited  and 
the  heart  beating  abnormally.  Palpation  of  the  apex  beat  in  very 
debilitated  subjects  is  often  difficult,  the  heart  being  very  weak.  Ab- 
dominal palpation,  while  usually  neglected,  may  be  useful  in  revealing 
dilated  stomachs  by  splash,  and  enlarged  mesenteric  or  retroperitoneal 
glands,  but  the  abdomen  of  such  patients  is  usually  too  tender  to  make 
glandular  palpation  easy. 

Peritoneal  friction  may  also  be  discovered  in  some  cases  of  peri- 
toneal tuberculosis.  Sahli  considers  a  firm  lumpy  band  between  the 
xiphoid  and  the  umbilicus  very  characteristic  of  tuberculosis  of  the 
omentum. 

Mensuration.- — The  weight  and  height  are  determined,  as  noted,  be- 
fore the  patient  undresses.  The  estimation  of  the  vital  capacity  is  best 
postponed .  until  after  auscultation,  as  the  deep  inspiration  necessary 
may  remove  scanty  rales.  Most  patients  can  be  taught  at  the  first  trial 
how  to  fill  the  lungs  fully,  and  then  to  exhale  evenly,  steadily,  and  com- 
pletely into  the  spirometer,  but  a  few,  especially  women  patients,  can 
never  learn  to  use  this  instrument.  The  wet  spirometer  is  the  only 
reliable  form.  The  use  of  the  sphygmomanometer  to  test  blood-pressure 
is  not  necessary  as  a  regular  part  of  the  examination,  the  finger  estima- 
tion of  pressure  being  sufficient.  The  tape,  for  reasons  of  cleanliness, 
had  best  be  of  steel. 

The  measurement  of  the  total  circumference  at  extreme  inspiration 
and  extreme  expiration  is  of  little  value,  but  the  determination  of  the 
circumference  of  each  half  of  the  chest  separately  in  inspiration  and 
expiration  is  useful,  often  revealing  limitations  of  motion  confined  to 
one  side,  or  decreases  in  size.     A  smaller  right  half  of  the  chest  in 


PHYSICAL   EXAMINATION  307 

right-lianded  persons  has  some  value  in  strengthening  other  signs.  The 
total  circumference  when  at  rest  should  be  noted  to  find  out  whether 
it  is  equal  to  one  half  the  patient's  height  as  it  should  be.  For  all 
tape  measurements  the  anterior  and  posterior  central  lines  should  be 
marked  on  the  sternum  and  spine  at  the  level  at  which  the  tape  is 
applied.  The  level  to  be  preferred  lies  between  the  fourth  ribs  in  front 
and  the  eighth  dorsal  spine  behind,  which  two  points  should  be  marked 
by  a  cross  or  vertical  line. 

The  Icdd  tape  cyrtomcter,  Avhile  it  has  fallen  into  disuse,  is  a  most 
useful  instrument,  not  simply  in  revealing  often  unsuspected  asym- 
metry, but  more  especially  in  showing  those  shrinkages  and  reexpan- 
sions  of  the  thorax,  which  are  so  common  in  the  disease,  and  which 
prognostieally  are  of  great  value.  The  elaborate  cyrtometers  of  the 
instrument  makers  are  not  necessary.  A  pair  of  simple  calipers,  capable 
of  being  opened  to  at  least  twelve  inches,  and  a  lead  tape  are  all 
that  is  necessary.  The  latter  can  be  made  by  any  pluml^er  from  three- 
sixteenth  sheet  lead,  and  should  be  half  an  inch  wide  and  tweny-six 
inches  long,  and  for  cleanliness  had  best  be  covered  with  calfskin  by  the 
shoemaker.  The  aim  is  to  get  a  graphic  record  of  the  horizontal  plane  of 
the  chest,  vertical  to  its  long  axis,  and  so  recorded  that  we  can  compare 
the  tracings  taken  at  one  examination  with  those  taken  at  another.  I 
have  found  it  convenient  to  use  the  instrument  at  the  level  of  a  plane 
cutting  the  fourth  rib  in  front  and  the  eighth  dorsal  spine  behind,  this 
plane  being  aljout  at  right  angles  to  the  axis  of  the  thorax,  being  low 
enough  to  miss  the  scapula  behind  and  the  axillary  folds. 

The  first  step  is  to  take  the  depth  of  the  thorax  between  these  points 
and  lay  it  out  on  the  chart,  which  should  be  large  enough  to  hold  the 
full  tracing  of  the  largest  chest — i.e.,  twelve  inches  wide  by  sixteen  inches 
long.  Sitting  facing  the  patient's  left  shoulder,  pass  the  tape  between 
the  body  and  the  right  arm  and  place  its  posterior  end  carefully  on  the 
eighth  spine,  taking  care  thereafter  that  it  does  not  slip  from  this  point. 
It  is  then  molded  from  behind  forward  to  fit  the  chest  snugly,  being 
careful  in  crossing  the  axilla  to  follow  its  outline,  and  not  arch  across 
it  as  can  be  so  easily  done.  As  the  tape  is  brought  around  toward  the 
sternum  it  is  best  to  roll  the  anterior  end  inward,  which  produces  a 
better  approximation.  The  snug  fit  of  the  tape  and  its  correct  position 
at  the  spine  behind  being  verified,  and  any  displacements  of  the  skin 
being  corrected,  the  patient's  chest  being  in  repose  and  not  expanded, 
mark  the  point  where  it  crosses  the  midline  in  front  and  remove  it  by 
raising  its  two  ends  and  slipping  it  off  the  chest  obliquely  without 
bending.  The  depth  of  the  chest  having  been  laid  out  on  a  line  which 
runs  across  the  chart,  the  two  ends  of  the  tape  are  made  to  correspond 
with  these  marks,  and  the  perimeter  is  then  traced  in  colored  pencil. 


308  PHYSICAL  EXAMINATION 

The  left  side,  being  similarly  taken,  is  laid  down  opposite  the  right,  the 
two  adjoining  end  to  end,  and  giving  an  accurate  reproduction  of  the 
perimeter  of  the  thorax.  When  this  simple  technic  is  once  mastered 
it  is  easy  to  take  absolutely  accurate  tracings,  which  will  correspond  with 
others  taken  the  same  day,  or  if  the  case  is  inactive  and  no  change  of 
form  takes  place,  the  tracings  taken  months  or  years  apart  will  corre- 
spond accurately. 

At  reexaminations  the  new  tracings  are  not  only  traced  on  the 
new  chart  for  that  examination,  but  also  over  the  old  tracings,  and 
marked  in  different  colors,  taking  care  to  first  lay  out  the  depth  by  the 
calipers,  as  this  may  change  between  examinations.  In  this  way  we  get 
very  striking  pictures  of  the  increase  or  decrease  in  size  of  the  patient's 
chest  under  treatment.  Aside  from  its  prognostic  use  it  demonstrates 
very  plainly  flattenings  or  distortions  of  the  thorax  and  differences  in 
the  two  sides.  Since  the  thorax  is  generally  largest  on  the  side  of  the 
arm  used  chiefly,  a  proper  interpretation  of  tape  measurements  or 
lead-tape  tracings  and  of  percussion  findings  demands  a  note  of  the 
patient's  right-  or  left-handedness,  which  should  be  marked  on  every 
chart. 

Prognostically  a  progressive  shrinkage  of  the  perimeter  during  the 
course  of  the  disease,  except  in  old  fibroid  cases,  where  it  is  compatible 
with  fair  health  and  a  relatively  stationary  troulile,  is  uniformly  a  bad 
sign.  Expansion  of  the  perimeter,  on  the  contrary,  especially  if  there 
is  deepening  of  the  anteroposterior  diameter,  is  imiformly  a  good  sign, 
and  the  writer  has  never  kno^Ti  such  expansion  and  deepening  to  occur 
except  in  improving  cases.  In  incipient  cases  reexpansion  of  the  chest 
occurs  first  on  the  affected  side,  the  good  side,  which  has  not  had  time 
to  shrink,  gaining  little  until  later.  In  old  cases,  on  the  contrary,  the 
least  affected  side  is  the  first  to  show  gains,  which  are  evidently  com- 
pensatory, and  only  later,  if  the  patient  improves,  will  expansion  on  the 
most  affected  side  be  found.  In  the  slight  scolioses  so  often  seen  in 
tuberculous  patients,  there  is  a  bulging  backward  of  the  ribs  on  the 
side  of  the  convexity,  and  if  the  patient  is  getting  along  well,  and  this 
scoliosis  disappears,  as  it  often  does,  the  disappearance  of  this  asym- 
metry is  shown  by  the  tracings. 

Technic  of  Percussion. — In  percussion  one  can  use  either  the  fingers 
alone  or  the  percussion  hammer  and  pleximeter.  In  this  country  the 
fingers  are  used  almost  universally.  While  in  a  few  cases  the  hammer 
may  be  useful,  in  the  large  majority  of  cases  the  results  of  finger-finger 
percussion  are  much  superior.  The  force  of  the  blow  is  more  under 
control,  the  note  is  purer  and  not  complicated  by  the  overtone  of  the 
pleximeter,  valuable  information  is  given  by  the  sense  of  resistance  in 
the  parts,  and  there  is  less  likelihood  of  percussing  too  hard. 


PHYSICAL   EXAMINATION 


309 


Fig.  65. 


Percussion,  however,  demands  a  perfect  technic,  and  if  the  technic 
is  poor  the  hammer  will  be  preferable.  A  perfect  technic  can  be 
acquired  in  a  short  time  by 
practice,  taking  the  piano 
hammer  as  a  model — i.  e.,  the 
blows  must  be  vertical  to  the 
part  percussed,  the  finger  must 
rebound  instantly,  and  the 
motion  must  be  absolutely 
confined  to  the  wrist  and  met- 
acarpophalangeal joints,  the 
rest  of  the  arm  being  held 
perfectly  motionless.  This  can 
be  practiced  by  laying  the 
forearm  flat  on  the  table  top 
and  practicing  vertical  blows 
on  the  table  with  the  finger, 
the  motion  being  necessarily 
limited  to  the  joints  men- 
tioned. The  middle  finger  is 
the  best  to  use,  for,  being 
nearer  the  center  of  the  hand, 
the  lilow  is  better  balanced, 
and  a  vertical  blow  and  a 
good  recoil  are  thus  more 
easily  obtained,  but  the  index 
finger  can  be  used  instead,  or 
even  the  ring  finger  in  an 
emergency.  Except  over  very 
muscular  backs,  two  fingers 
should  never  be  used,  as  this 
favors  unduly  hard  percussion 
and  does  not  give  a  pure 
note  (see  Figs.  65,  G6,  67). 

The  pleximeter  may  be  any 
of  tlie  four  fingers,  though 
usually  the  middle  finger,  or 
the  index  of  the  left  hand,  is 
best,  ])ut  over  the  apex,  or 
when     outlining     areas     with 


Fig.  66. 

Figs.  65  and  66. — Proper  Position  of  the 
Fingers  and  Wrists,  the  Motions  Being 
Altogether  in  the  Wrist  Joint  and 
the  Metacarpophalangeal  Joint  of 
the  Second  Finger  of  the  Right  Hand, 
THE  Blow  Being  Vertical,  Light  (65) 
AND  Rebounding  (66),  the  Pleximeter 
Finger  Being  Laid  in  the  Interspace 
Parallel  to  the  Course  of  the  Ribs. 


precision,    or    in    children,    or 

in  subjects  with  narrow  interspaces,  tlie  little  finger  is  to  be  preferred. 

The  •finger  must   be  applied   evenly,  but  not   too   firmly;  the  blow  of 


310 


PHYSICAL  EXAMINATION 


the  percussing  finger  must  never  he  oblique,  but  absolutely  vertical 
if  the  resultant  note  is  to  be  pure,  while  the  rebound  must  be  instan- 
taneous to  allow  of  the  vibration  of  the  parts,  excejjt  only  in  eliciting 

cracked-pot  resonance,  when  it 
should  remain  in  contact  for 
a  moment.  The  blows  must  be 
even  in  force,  not  too  rapidly 
re])eated,  and  in  doubtful  cases 
sbould  occur  during  tbe  same 
pliase  of  respiration,  since  the 
note  during  inspiration  and 
expiration  is  not  identical. 
Usually  two  successive  blows, 
regularly  given,  produce  the 
best  impression  on  tbe  ear,  but 
in  cases  where  sliglit  differ- 
ences between  tbe  apices  are 
suspected,  single  blows  over 
each  apex  in  turn  are  useful. 
It  is  also  better,  in  doubtful 
cases,  to  percuss  upward  toward 
tbe  diseased  area  ratlier  than 
to  begin  over  the  impaired  area 
and  percuss  downward,  finer 
distinctions  ])eing  ol)tainable  in 
tills  way. 
Although  every  writer  on  the  subject  has  dwelt  on  it,  too  much 
stress  cannot  be  laid  on  the  importance  of  light  percussion  in  the  large 
majority  of  cases  and  localities,  the  occasions  when  heavy  percussion 
is  needed  being  increasingly  rare  with  increasing  skill  of  percussion. 
No  faults  of  percussion  are  so  common  as  unduly  heavy  or  oblique 
blows,  and  he  who  would  percuss  well  must  avoid  them.  The  aim  is 
not  to  produce  the  loudest  sound  possible,  but  the  clearest  and  purest, 
and  if  the  blow  is  quick,  resilient,  and  very  light,  we  will  attain  the  best 
results,  and  added  force  Avill  not  increase,  but  lessen  the  clearness  of 
the  resulting  sounds,  and  give  rise  to  confusing  vibrations  from  remote 
parts.  Only  when  we  desire  to  detect  deep-seated  foci  of  condensation, 
or  when  percussing  over  very  thick  layers  of  muscles  or  fat,  should 
deep  percussion  be  practiced,  and  the  practice  of  hard  percussion  to  re- 
veal suspected  tympany  in  the  search  for  cavitation  is  al)solutely  useless, 
tympany  so  produced  being  more  likely  to  come  from  deep-seated  large 
bronchi  than  from  excavations,  while  such  violent  Idows  can  have  a  harm- 
ful effect  on  the  diseased  lung,  and  not  infrequently  produce  hemorrhages. 


Fig.  67. — To  Show  the  Use  of  the 
Little  Finger  in  Delicate  Percus- 
sion, IN  this  Case,  of  the  Outline  of 
Apical  Resonance.  Percussion  is  here 
outward  from  the  clear  area  toward  the 
dull,  but  this  can  be  reversed.  Note  the 
very  moderate  amount  of  wrist  motion  in 
light  percussion,  the  chief  motion  being 
in  the  metacarpophalangeal  joint. 


PHYSICAL  EXAMINATION 


311 


Fig.  68. 


The  percu.ssion  should  be  of  two  kinds:   (1)   Comparative,  in  which 
alternate  blows  are  delivered  on  corresponding  parts  of  the  two  sides, 
and   (2)    unilateral,  in  which 
percussion    is   limited   to    one 
lung.    Ordinarily  percussion  is 
best  jDcrfornied  during  shallow 
respiration,    but    comparative 
percussion      during      extreme 
inspiration   and   expiration    is 
at   times    necessary    to    reveal 
slight  differences.    Tbe  patient 
should  l)e  seated  easily  erect, 
with  his  arms  hanging  by  his 
side  and  his  head  strictly   in 
midline    for    anterior    percus- 
sion ;  Avith  the  arms  on  top  of 
the  head,  and  the  elbows  held 
well     backward     for     axillary 
percussion;  and  bent  forward 
moderately    from    the    waist, 
not  fi-om   the  shoulders,  with 
the  head  slightl}^  drooped  and 
the    arms   lightly   crossed    for 
posterior    percussion.       When 
the  areas  covered  by  the  scap- 
ulae  are  to  be  examined,   the 
patient   should   place   his   fin- 
gers behind  the  posterior  ax- 
illary folds  on  opposite  sides, 
which  will  uncover  all  of  the 
lung  it  is  possible  to  get   at. 
During    percussion,    positions 
wliicli  make  tbe  muscles  tense 
or    distort    the    symmetry    of 
the  thorax,  such  as  straddling 
a  chair,  are  to  he  avoided,  the 
most  undistiirbed  easy  ])osition 
always  being  l)est.    Brown  has 
noted  that  the  volume  of  the 
percussion  note  can  be  increased  l)y  standing  the  patient  in  ibe  angle 
between  two  walls. 

The  first  step  of  a  percussion  should  l)o  the  marking  out  of  all  the 
lung  borders  with  a  skin   ])('iicil.   and  this  should   be  omitted   from  no 


Figs.  68  and  69. — Fibroid  Tuberculosis 
OF  Six  Years'  Duration  in  a  Man  of 
Fifty-six  in  which  the  Fat  Hides  the 
Shrinkage  of  the  Chest,  avhich  in 
Any  Case  is  Moderate.  Only  the  limi- 
tation of  the  resonant  areas  in  the  right 
apex  are  noticeable  with  slight  limitation 
of  motion  at  the  right  base. 


312 


PHYSICAL  EXAMINATION 


Fig.  70. 


Fig.  71. 

Figs.  70  and  71. — To  Show  the  Deforming 
Effect  of  Pulmonary  Tuberculosis 
UPON  THE  Thorax.  Chest  of  an  athlete, 
in  which  right-sided  tuberculosis  (stage 
II)  had  existed  for  two  years.  The 
shrinkage  of  the  right  side  as  compared 
to  the  left  side  is  well  shown,  as  also 
the  falling  in  of  the  regions  below  the 
nipples.  There  is  right  shoulder  droop, 
retraction  of  the  right  base  and  of  the 
right  apex.  The  flattening  of  the  for- 
merly prominent  chest  walls  is  well 
shown  in  the  three  quarters  view. 


examination,  as  it  will  greatly 
improve  the  accuracy  of  the 
work  and  guard  against  over- 
looking any  portion  of  the 
lung  in  the  examination.  The 
base  line  should  l)e  marked 
all  around  during  shallow 
breathing,  while  in  the  mam- 
mary line  in  front  and  in  the 
scapular  line  hehind  tlie  base 
line  should  be  marked  on 
deep  inspiration,  recording 
the  excursion  of  the  lower 
borders  of  the  two  lungs  on 
the  chart. 

Apical  Percussion.  —  The 
])ercussory  projection  of  the 
apical  outline  ("  isthmus ") 
proposed  by  Kroenig  ('89) 
the  writer  has  practiced  for 
a  number  of  years,  and  has 
found  it  a  very  valuable  pro- 
cedure. The  pathologic  fact 
on  which  its  value  depends  is 
the  well-recognized  tendency 
of  the  apex  of  the  lung,  and 
the  lung  as  a  whole,  to  shrink 
when  a  tuberculous  focus  de- 
velops in  it,  not  alone  from 
fibrosis,  but  even  before  any 
fibrosis  occurs  through  the 
lessened  functional  activity 
produced  by  the  disease.  Le- 
Grange  has  noted  the  rapid 
modification  of  the  volume  of 
the  lung  coincident  with  in- 
crease or  decrease  of  func- 
tion. Were  apical  shrinkage 
due  to  fibrosis  alone,  their  de- 
termination would  naturally 
be  of  no  value  in  early  diag- 
nosis, but  since  the  lung  de- 
creases  in   size   when   disused 


PHYSICAL  EXAMINATION 


313 


or  when  disease  is  developing  in  it,  such  shrinkage  becomes  a  valu- 
able early  sign.  As  great  accuracy  is  desirable,  the  little  finger  is 
best  used  as  a  pleximeter,  and  the  percussion  stroke  must  be  deliv- 
ered very  carefully  and  cor- 
rectly, only  the  most  perpen- 
dicular, elastic,  light  stroke 
being  desirable,  and  the  pa- 
tient's head  must  be  held  ex- 
actly in  tlie  middle  line  to 
avoid  uneven  tension  of  the 
muscles. 

Percussion  of  the  inner  an- 
terior line  should  start  well  up 
the  side  of  the  neck  above  the 
lung,  coming  slowly  downward 
until  pulmonary  resonance  is 
found,  the  spot  being  marked 
by  a  dot  with  the  skin  pencil. 
Working  from  behind  forward, 
the  whole  line  is  mapped  out, 
which  is  slightly  concave  in- 
ward above,  becoming  rather 
convex  inward  in  the  lower 
third  of  its  course,  and  end- 
ing rather  indefinitely  Just  ex- 
ternal to  the  sternoclavicular 
joint,  the  bones  here  making 
accuracy  difficult. 

The  outer  border  should 
be  approached  from  the  shoul- 
der and  marked  in  the  same 
way.  It  is  steeper  than  the 
inner  and  runs  downward  and 
outward,  with  its  concavity 
outward  to  the  junction  of  the 
inner  and  outer  third  of  the 
clavicle.  The  posterior  lines 
are  marked  in  tlie  same  way. 
The  normal  level  of  the  apex 
behind,  according  to  Kroenig, 
is  that  of  the  first  dorsal 
spine,  and  it  is  2  to  2.4 
inches  outside  the  midline  of 


Fig.  72. 


Fig.  73. 

Figs.  72  and  73. — Tuberculosis  of  Left 
Apex.  Note  slight  limitations  of  area 
of  resonance  at  apex  and  of  motion  of 
left  base.  Also  flattening  of  outline  of 
anterior  chest  wall  as  shown  in  side  view. 


314  PHYSICAL   EXAMINATION 

the  spine.  The  inner  line  converges  with  its  convexity  toward  the 
spinal  column,  until  it  reaches  the  level  of  the  lower  border  of 
the  second  dorsal  vertebra,  when  it  runs  downward  parallel  and  half 
an  inch  from  the  spine.  The  posterior  external  line  the  writer  has 
found  to  run  downward  with  its  concavity  outward  and  to  terminate 
with  great  regularity  at  the  middle  of  the  spine  of  the  scapula.  The 
lines  having  been  percussed  out,  they  should  be  inspected  carefully,  and 
even  in  very  early  cases  there  is  often  found  some  degree  of  dislocation 
inward  of  one  or  more  of  them.  The  dislocation  is  chiefly  in  the  inner 
line,  but  dislocation  of  the  outer  line  is  also  common,  as  the  writer  has 
determined  again  and  again  by  careful  percussion.  In  early  cases  the 
demarcation  between  resonance  and  dullness  is  less  sharply  pronounced 
than  in  the  normal  lung,  being  as  it  were  "  blurred."' 

Goldscheider  ("O?)  recently  objected  to  Kroenig's  work  on  the 
ground  that  the  resonant  area  thus  outlined  does  not  correspond  to 
the  anatomic  apex,  being  only  a  projection  field  of  lung  resonance. 
This  cannot  be  denied,  but  since  these  fields  decrease  in  direct  propor- 
tion to  the  contraction  of  the  underlying  lung,  their  determination  does 
not  thereby  lose  in  clinical  value,  and,  unlike  Goldscheider's  method, 
the  outlining  is  sufficiently  simple  to  be  applied  by  anyone  well  skilled 
in  percijssion.  Goldscheider,  by  the  use  of  a  bent-glass  rod  pleximeter, 
percusses  out  the  absolute  height  of  the  apex  anteriorly  and  posteriorly. 
After  having  used  his  instrument  and  method,  the  writer  has  found  that 
the  absolute  area  can  be  so  percussed,  but  the  method  is  much  more 
complex  and  the  results  not  more  satisfactory  than  those  of  Kroenig. 

The  lung  borders  being  marked  out,  the  percussion  of  the  lung  should 
be  commenced.  This  usually  begins  over  the  apices  in  the  inner,  mid- 
dle, and  outer  zones  in  succession,  comparing  these  from  side  to  side, 
and  thus  small  areas  of  dullness  are  often  discovered  that  otherwise  may 
be  overlooked,  one  zone  at  times  being  dull  when  others  are  clear. 

When,  owing  to  emaciation,  the  supraclavicular' fossa  is  a  deep  hole, 
percussion  of  the  apices  should  take  place  from  above  and  behind.  We 
should  also  not  omit  to  percuss  the  clavicle  directly,  without  the  use 
of  a  pleximeter,  as  at  times  this  bone  will  give  a  dull  note  when  above 
and  below  is  clearness,  and  if  we  can  exclude  old  fractures  and  uni- 
lateral abnormalities  of  the  bone,  such  information  is  valuable. 

The  remainder  of  the  chest  should  now  be  studied,  taking  pains  to 
percuss  absolutely  symmetrical  points  and  not  to  miss  any  portion  of 
any  interspace.  Turban  notes  the  necessity  of  not  neglecting  the  apex 
of  the  axilla,  a  necessary  warning,  since,  owing  to  motives  of  niceness, 
one  is  apt  to  avoid  this  region.  The  heart  should  always  be  mapped  out 
on  the  anterior  chest  wall,  care  being  taken  not  to  overlook  small  areas  of 
dullness  on  each  side  of  the  sternum,  due  to  enlarged  bronchial  glands. 


PHYSICAL   EXAMINATION 


315 


The  back  demands  firmer  percussion  than  the  front,  and  in  fat  or 
very  muscular  persons  percussion  of  this  region  may  be  most  unsatis- 
factory.    Small  areas  of  dullness  at  the  extreme  base  behind,  from  an 


i'lG.  7t).  Fig.  77. 

Figs.  74  to  77. — Typical  Case  of  Fibroid  Phthisis  of  Left  Lung  in  Case  of 
Four  Years'  Duration.  Note  shrinkage  of  left  side,  dislocation  of  heart  to 
left  (right  border  to  left  of  sternum,  apex  five  and  one  quarter  inches  outside 
midline).'  Extreme  limitation  of  resonant  area  at  left  apex,  anterior  and 
posterior  areas  not  joining,  limit  of  motion  of  left  base. 

old  pleurisy,  arc  easily  missed  unless  the  bases  are  carefully  marked. 
When  scoliosis  exists,  producing  abnormal  arching  of  the  ribs,  percussion 
over  such  arched  regions  is  more  or  less  dull  and  percussion  in  scoliotic 
cases  is  not  to  be  relied  on  implicitly. 

Technic  of  Auscultation. — Usually  and  logically  auscultation  is  the 
last  step,  as  it  is  unquestionably  the  most  important,  of  a  physical  exam- 


316  PHYSICAL  EXAMINATION 

ination,  but  some  have  advocated  placing  it  first,  so  that  the  deep 
breathing  necessitated  by  some  of  the  preceding  steps  may  not  remove 
scanty  adventitious  sounds  which  may  be  of  importance  in  diagnosis. 

In  doubtful  incipient  cases  this  may  be  necessary,  but  in  such  it  is 
better,  when  the  examination  shows  the  case  to  be  a  suspicious  one,  and 
we  suspect  rales  we  cannot  detect,  to  repeat  the  auscultation  on  another 
day,  soon  after  the  patient  wakes,  when  such  sounds  are  found  most 
easily.  Ordinarily  it  is  best  to  place  auscultation  last,  as  this  tends  to 
give  a  more  complete  idea  of  the  case,  the  various  facts  discovered  by 
the  other  steps  leading  the  mind  logically  onward  and  preparing  it  for 
a  proper  interpretation  of  the  auscultatory  findings,  a  knowledge  of 
which  enables  us  to  correlate  them  into  a  complete  whole.  Moreover, 
if  it  is  performed  first,  it  tempts  us  to  slur  over  the  other  steps  which 
follow  it,  and  we  fail  to  get  that  broad  view  of  the  case  which  can  only 
come  from  a  consideration  of  all  the  discovered  facts. 

The  teclmic  of  auscultation  is  simpler  than  is  that  of  percussion, 
but  it  needs  a  careful  training  of  the  ear,  and  if  the  physician  has  a 
musical  ear  it  will  be  of  gre«t  assistance. 

Auscultation,  may  be  either  immediate  or  mediate.  In  the  former 
the  ear  is  laid  directly  on  the  chest,  in  the  latter  the  sound  is  conveyed 
to  the  ear  by  an  instrument,  practically  always  a  single  or  double  tube. 
While  the  sound  heard  by  immediate  auscultation  is  very  pure  and  gives 
an  idea  of  the  condition  of  a  larger  area  of  lung,  it  is  faint,  not  sharply 
localized,  and  the  finer  adventitious  sounds  can  be  missed  by  it.  More- 
over, the  ear  cannot  be  placed  in  the  supraclavicular  fossa,  and  ofteii  not 
in  the  infraclavicular;  the  method  brings  one  into  disagreeably  close 
contact  with  the  patient's  body,  and  it  often  necessitates  very  strained 
attitudes  for  the  physician. 

For  these  reasons  mediate  auscultation  is  the  method  most  commonly 
used,  but  the  other  should  not  be  neglected  entirely,  since  certain  types 
of  breathing,  notably  bronchial,  are  heard  more  distinctly  and  typically 
by  it,  and  it  gives  one  an  excellent  general  impression  of  the  lung  as 
a  whole. 

Mediate  auscultation,  devised  by  the  great  Laennec,  is  performed  by 
the  use  of  the  stethoscope.  This  instrument  is  either  for  use  with  one 
ear  (monaural)  or  with  both  ears  (binaural),  the  former  having  been 
invented  by  Laennec  in  1816,  the  latter  by  Dr.  Camman,  of  New  York, 
in  1840.  The  binaural  stethoscope  is  in  universal  use  in  this  country, 
the  monaural  on  the  Continent ;  and  the  clinicians  of  the  Continent 
and  those  of  America  seem  unable  to  agree  as  to  the  merits  of  these 
instruments.  Aside  from  custom,  whose  large  part  in  the  settlement  of 
this  question  for  any  individual  practitioner  should  not  be  forgotten, 
the  reasons  which  have  caused  the  profession  of  this  country  to  reject 


PHYSICAL  EXAMINATION  317 

the  monaural  stethoscope  are:  the  very  awkward  and  strained  attitude 
necessary  in  its  use,  the  inability  to  control  its  position  and  application 
by  the  eye,  the  difficulty  of  avoiding  undue  pressure  upon  it  by  the 
doctor's  head,  and  the  fact  that  the  sounds  it  transmits,  while  pure,  are 
unduly  faint,  and  that  certain  sounds  can  escape  entirely.  Sahli  criti- 
cises the  binaural  stethoscope  for  its  complexity,  for  the  false  sounds 
which  he  considers  are  created  in  it,  and  for  unduly  magnifying  and 
distorting  the  sounds  which  it  transmits. 

While  some  binaural  stethoscopes  are  complex,  the  best  type  is  prac- 
tically as  simple  as  the  monaural,  and  if  it  is  without  joints,  as  a  good 
stethoscope  should  be,  it  produces  in  itself  no  confusing  sounds,  and 
though  it  moderately  magnifies  the  sound  as  heard  by  immediate  aus- 
cultation, as  well  as  the  monaural,  in  a  lesser  degree,  this  magnification, 
if  moderate  (as  it  is  in  good  instruments),  is  an  advantage  rather  than 
a  disadvantage.  However,  the  chief  advantage  which  the  binaural 
stethoscope  possesses  is  the  fact  that  it  allows  the  physician  the  maxi- 
mum amount  of  ease  and  relaxation  during  his  examination,  and  this, 
as  noted  elsewhere,  is  essential  if  he  is  to  properly  concentrate  himself 
on  the  sounds  to  which  he  is  listening.  For  these  reasons,  what  follows 
refers  entirely  to  the  use  of  the  binaural  stethoscope  and  of  the  directly 
api^lied  ear. 

.  A^arious  forms  of  binaural  stethoscope  have  been  invented,  but  the 
simplest  is  the  best,  and  for  this  reason  the  writer  prefers  what  the 
instrument  dealers  catalogue  as  Snofton's  English  model.  This  consists 
of  a  simple  metal  and  hard-rubber  chest  piece,  two  metal  conducting 
tubes  connected  by  a  curved  spring,  and  hard-rubber  ear  pieces,  the 
chest  piece  and  ear  pieces  being  united  by  rubber  tubes.  This  instru- 
ment is  extremely  simple,  and  for  all  practical  purposes  as  simple  as 
the  monaural. 

In  buying  a  stethoscope  the  physician  should  see  to  it  that  the  curves 
of  the  tubes  are  such  as  to  tit  the  axis  of  the  canals  of  his  ears,  and 
that  the  shape  of  the  rubber  ear  pieces  is  such  as  to  accommodate  itself 
well  to  his  canals.  The  spring,  while  firm  enough  to  keep  the  ear  pieces 
in  close  contact  with  the  ears,  must  not  produce  undue  pressure.  The 
chest  piece,  which  is  best  made  of  hard  rubber  or  ivory,  screwing  into 
metal,  should  not  be  over  seven  eighths  of  an  inch  in  diameter,  and  its 
cavity  can  either  be  conical,  the  apex  of  the  cone  running  into  the  two 
tube  openings,  or  almost  hemisplierical,  with  one  central  opening  at 
the  top  branching  into  the  two  tubes.  The  edge  should  be  rounded,  but 
not  too  thick.  The  rubber  tubing  which  connects  the  chest  piece  with 
the  ear  piece  should  be  perfectly  flexible,  yet  tliick  enough  not  to  kink 
when  quite  sharply  bent.  The  only  absolutely  satisfactory  tube  for  this 
purpose    is    a   good,    rather   thick-walled,    smooth    stomacli-tube.      The 


318  PHYSICAL   EXAMINATION 

lengtli  of  tlie  tube  slioidd  not  be  less  tban  eight  inches  nor  more  than 
twelve,  ten  inches  being  the  best,  allowing  amply  for  motion  and  cliange 
of  position  without  kinking. 

Stethoscopes  meant  to  magnify  the  sound  by  the  use  of  diaphragms, 
of  which  the  plionendoscope  is  the  best-known  exam})le,  tend  to  lessen 
the  acuity  of  the  physician's  hearing,  though  useful  at  times  for  auscul- 
tating indistinct  sounds  or  for  those  who  are  hard  of  hearing.  Of  course 
every  stethoscope  magnifies  somewhat,  but  the  very  moderate  magnifica- 
tion found  in  such  a  stethoscope  as  advocated  strikes  the  happy  mean 
between  the  faintness  of  sound  of  the  monaural  and  the  undue  loudness 
of  the  plionendoscope.  Cabot  recommends  the  Bowles'  stetlioscope, 
which  differs  from  the  instrument  described  in  the  chest  piece,  which 
is  two  inches  in  diameter,  very  slightly  hollowed  out,  and  covered  with 
a  hard-rubber  diaphragm.  It  seems  to  share,  in  a  lesser  degree,  the 
disadvantages  of  tlie  plionendoscope,  and  to  unduly  magnify  the  sound, 
but  Cabot  says  the  diaphragm  does  not  act  in  this  way,  since  the  instru- 
ment acts  as  well  when  it  is  cracked.  In  any  case,  in  the  choice  of  a 
stethoscope,  tlie  important  thing  is  that  tlie  physician  should  accustom 
himself  thoroughly  to  the  use  of  one  instrument,  and  use  that  exclusively. 
In  this  way  any  instrument  will  be  found  to  yield  satisfactory  results, 
though  the  awkward  positions  necessitated  by  the  monaural  stethoscope 
are,  to  my  mind,  an  irremovable  handicap  to  its  utility. 

The  only  other  instrumental  equipment  necessary  in  auscultation  is 
a  pot  of  cold  cream  vaselin  and  a  spatula,  which  is  often  very  necessary 
in  anointing  patients  whose  skins  are  harsh,  scaly,  or  hairy. 

Position. — The  patient  should  be  seated  opposite  and  within  easy 
reach  of  the  physician,  his  hands  hanging  by  his  sides  or  lightly  crossed 
in  his  lap,  and  his  body  in  an  easy,  symmetrical  position.  The  physician 
should  be  seated  comfortably  not  too  far  from  the  patient,  witli  absolute 
ease  and  relaxation  on  the  part  of  the  physician  and  tlie  patient  if  the 
former  is  to  absolutely  concentrate  his  undivided  attention  on  the  sounds 
in  the  chest,  undisturbed  by  uncomfortable  or  strained  attitudes,  and  if 
the  latter  is  not  to  produce  muscular  sounds  in  tense  muscles. 

Before  beginning  the  auscultation,  it  is  a  matter  of  no  little  impor- 
tance to  listen  carefully  to  the  patient's  method  of  breathing.  The 
majority  of  patients  produce  some  sound  in  their  noses  on  moderately 
deep  or  deep  breathing,  or  even  sometimes  on  quiet  breathing,  these 
sounds  being  transmitted  to  the  chest  and  affecting  the  pitch  and  qual- 
ity of  the  expiratory  and,  less  often,  of  the  inspiratory  sound.  Opening 
the  mouth  is  not  always  sufficient  to  cure  this,  many  patients  continuing, 
nevertheless,  to  breathe  through  the  nose,  others  producing  a  loud  bron- 
chial sound  in  the  throat,  and  a  few  a  sibilant  sound  against  the  teeth. 
But  if  one  will  take  pains  to  breathe  properly  for  them,  they  will  learn 


PHYSICAL   EXAMINATION  319 

quickly  to  respire  normally  and  silently,  even  during  deep  breathing, 
by  opening  their  mouths,  and  to  maintain  during  deep  breathing  the 
normal  relation  of  inspiration  to  expiration.  Some  patients,  however, 
can  never  learn  this,  especially  those  with  perforated  septums,  and  such 
are  very  difficult  to  auscultate. 

Having  taught  the  patient  how  to  breathe,  and  being  sure  that  he 
is  not  cold,  since  this  can  produce  shivering,  and  thus  muscular  sounds, 
the  auscultation  may  be  begun.  It  should  alwa3's  be  carried  out  in 
two  separate  portions.  First,  directing  attention  entirely  to  the  breath 
sounds,  and  neglecting  any  adventitious  sounds,  study  their  pitch,  in- 
tensity, duration,  rhythm,  and  quality.  This  should  be  comparative, 
exactly  similar  spots  on  each  side  from  top  to  bottom  of  each  lung 
being  compared,  ins})iration  with  inspiration,  expiration  Avith  expira- 
tion  (Grancher),  noting  also  tlie  relation  of  inspiration  to  expiration. 

By  concentrating  attention  entirely  on  the  breath  sounds  one  scarcely 
hears  any  rales.  Such  comparative  auscultation  should  first  be  made 
during  quiet,  easy  breathing  over  the  whole  lung,  and  then  during  mod- 
erately deep  breathing.  Deep  breathing  should  not  be  used  in  the  aus- 
cultation of  breath  sounds,  since  during  it  they  are  never  entirelv  nor- 
mal, but  moderately  deep  breathing,  well  performed,  will  at  times  reveal 
bronchovesicular  breatliing  which  would  be  missed  on  quiet  breathing. 
Care  nnist  be  taken  to  cover  every  portion  of  the  lung  area,  the  chest 
piece  of  tlie  stethoscope  being  applied  along  the  whole  length  of  each 
interspace,  not  omitting  the  apex  of  tlie  axilla,  the  pleural  sinus,  the 
body  of  the  scapula,  and  the  area  of  cardiac  dullness. 

Beginning  over  the  apices  whose  inner,  middle,  and  outer  zones  must 
be  auscultated,  ])roceed  downward  in  slightly  diverging  lines  so  as  to 
cover  tlie  whole  anterior  lateral  and  posterior  aspects ;  in  this  way  noth- 
ing will  be  missed.  Finally,  we  should  study  the  breath  sounds  in 
different  portions  of  the  same  lung,  noting  the  relations  of  inspiration 
to  expiration,  and  remembering  the  normal  variations  in  the  sounds  in 
various  regions.  Before  completing  comparative  auscultation,  vocal  reso- 
nance must  also  be  tested,  remembering  that  it  is  best  judged  by  the 
use  of  the  whispered  voice. 

The  results  of  tlie  auscultation  being  noted  on  the  chart  wliile  still 
fresh  in  mind,  one  should  turn  to  the  second  jjortion  of  tlie  auscultation, 
which  the  writer  calls  unilateral  aiiscuUuiion,  in  which  attention  is 
directed  only  to  adventitious  sounds.  This  is  the  most  delicate  part  of 
auscultation,  and  demands  the  most  concentrated  attention.  For  this 
reason  the  patient  should  sit  close  beside  the  physician,  but  facing  the 
other  way,  and  close  enough  so  that  the  stethoscope  may  easily  be  placed 
on  any  ])art  of  the  chest.  The  type  of  breathing  used  should  be,  first, 
natural    breathing,    then    moderately    deep    breatliing,    then    very   deep 


320  PHYSICAL  EXAMINATION 

breathing,  and  finally  deep  breathing  preceded  or  followed  by  a  short 
cough,  rales  which  are  absent  at  first  often  appearing  on  deeper  breath- 
ing. Xaturall}',  those  rales  heard  easily  on  quiet  breathing  speak  for 
a  more  advanced  process  than  those  which  can  only  be  elicited  by  deep 
or  forced  breathing.  The  writer  usually  has  the  patient  cough  just 
before  taking  a  deep  breath;  Babcock,  of  Chicago,  prefers  to  have  the 
patient  cough  Just  at  the  end  of  a  deep  breath;  Brown,  of  Saranac,  has 
recently  recommended  cough  following  a  complete  expiration,  and  fol- 
lowed by  a  complete  inspiration.  If  the  cough  precedes  the  breathing 
the  patient  must  be  told  to  avoid  that  act  of  swallowing  after  the  cough 
which  is  natural  with  most  people,  and  which  can  produce  deceptive 
esophageal  sounds.  Of  the  rales  heard,  the  phase  of  respiration  in  which 
they  occur  should  be  noted,  as  well  as  their  size,  their  quality,  and  their 
appearance  on  natural  or  forced  breathing.  The  physician  should  use 
some  convenient  system  of  signs  for  recording  breath  changes  and  adven- 
titious sounds,  thus  simplifying  his  charts.  Such  a  system  will  be  found 
in  the  Appendix. 

Technic  of  Roentgen  Examination. — If  used  only  occasionally,  the  in- 
formation the  fl.uoroscope  can  give  hardly  compensates  for  its  great  cost, 
and  unless  it  is  used  frequently  and  systematically  the  physician  will 
not  develop  sufficient  skill  in  its  use  in  chest  work  to  avoid  the  many 
possible  sources  of  error  in  interpreting  the  shadow  picture,  and  he  is 
apt,  therefore,  to  be  misled  ratlier  than  helped  by  it.  If,  however,  the 
physician  will  use  the  fluoroscope  regularly  in  all  his  cases  he  will  soon 
develop  such  a  familiarity  with  it  as  to  get  from  it  great  assistance. 

The  essentials  are  a  dark  room;  a  source  of  electric  current,  either 
to  actuate  the  coil  or  to  drive  the  plates  of  the  static  machine,  though 
for  the  latter  a  water  motor  can  be  used ;  a  device  for  interrupting  the 
current,  perfectly  insulated  conducting  cords,  a  Eoentgen-ray  bulb,  an 
adjustable  stand  to  hold  the  bulb,  a  large  fluorescent  screen  in  a  rectan- 
gular frame,  and  a  large  protective  lead  screen.  The  current  can  be 
obtained  from  an  induction  coil,  or  produced  in  a  static  machine,  driven 
by  electric  or  water  motor,  hand  power  being  useless  for  practical  work. 
The  coil  is  more  popular,  being  less  bulky,  not  affected  by  weather,  and 
yielding  a  powerful  light.  The  static  machine  is  preferable  for  fluoroscopy 
because  of  its  steadier  light,  intensity  after  a  certain  point  being  a  disad- 
vantage rather  than  an  advantage,  and  secondary  in  importance  to  steadi- 
ness because  of  the  very  greatly  increased  life  of  the  tube,  and  the  simpler 
and  therefore  much  cheaper  tube  which  can  be  used.  It  is  also  less  likely 
to  produce  harmful  effects  on  the  patient  (dermatitis)  or  physician 
(azoospermia). 

If  a  coil  is  used  it  should  be  capable  of  producing  from  an  eight-  to  a 
sixteen-inch  spark ;  if  a  static  machine,  it  must  be  well  and  strongly  built. 


PHYSICAL   EXAMINATION  321 

with  not  le^;s  than  eight  thirt3'-inch  revolving  plates,  and  should  produce 
at  least  a  twelve-inch  spark  under  good  conditions,  and  must  be  run  at  at 
least  500  revolutions  per  minute.  It  must  be  kept  in  a  dry  room,  and  in 
damp  weather  kept  dry  by  keeping  calcium  chlorid  in  the  case.  When 
once  understood  it  should  run  every  da}-  in  the  year  without  difhculty. 

An  interrupter  for  use  with  a  coil,  or  with  a  static  machine  a  mul- 
tiple spark-gap,  is  essential.  Much  of  the  failure  to  get  proper  results 
with  the  static  machine  has  come  from  failure  to  heed  Williams's  advice 
to  use  a  multiple  spark-gap,  the  single  spark-gap  on  the  pole  of  the 
machine  being  entirely  useless.  By  it  the  penetration  of  the  tube  can 
be  raised  or  lowered  at  will,  an  essential  thing  in  the  study  of  the 
lungs,  under  different  conditions  or  penetration,  either  to  reveal  areas 
of  shadow  invisible  with  bigh-vacuum  tuljes,  or  to  penetrate  thick  chests, 
opaque  until  a  series  of  sjjarks  is  introduced  into  the  current. 

The  apparatus  is  simply  a  series  of  brass  balls  inserted  in  the  course 
of  the  current,  and  so  arranged  that  the  current  can  be  made  to  .jump 
the  gaps  between  a  given  number  of  balls  at  will.  Each  new  gap 
inserted  in  the  circuit  raises  the  penetration  of  the  tube,  so  that  a  tube 
of  such  low  vacuum  that  it  will  not  penetrate  the  chest  at  all  can  be 
raised  until  it  accjuires  any  necessary  degree  of  penetration.  This  ap- 
paratus must  be  close  by  the  observer's  hand,  so  that  he  can  make 
the  changes  instantaneously,  and  without  removing  his  eyes  from  the 
screen. 

The  cords  must  be  thickly  and  well  insulated,  as  the  high-tension 
current  used  will  leak  from  ordinary  ones.  The  hulh  for  thoracic  work 
should  be  of  the  lowest  vacuum  tliat  will  give  a  clear  picture.  A  bulb 
that  will  liglit  up  with  a  one-half-inch  or  a  one-inch  gap  between  the 
poles  is  satisfactor}'.  Bulbs  to  be  used  with  a  coil  need  a  heavy  platinum 
cathode,  with  some  arrangement  for  keeping  the  cathode  cool,  and  an 
apparatus  to  lower  the  vacuum  when  it  gets  too  liigh,  since  with  a  coil 
the  vaciuim  rises  very  rapidly,  until  a  nonadjustable  tube  is  soon  use- 
less. Such  tubes  are  very  expensive  and  add  greatly  to  the  cost  of 
ajjparatus. 

With  the  static  machine  the  cathode  can  be  of  light  platinum,  needs 
no  cooling  device,  and,  as  the  vacuum  rises  very  slowly,  an  adjusting 
apparatus  is  not  needed,  such  a  tube  lasting  for  a  year  or  two  in  daily 
use,  while  for  the  same  reason  a  six-inch  tube  is  sufficiently  large.  Six- 
inch,  light  anode,  nonadjustable  tubes  of  the  best  make  are  very  rea- 
sonable in  price  and  are  cheaper  to  use,  until  too  high  for  satisfactory 
use,  and  then  get  a  new  one  rather  than  buy  expensive  adjustable  tubes. 
Laid  aside  for  six  months  or  a  year,  high  tubes  reduce  their  vacuum 
and  can  often  be  used  again  later.  Care  must  be  taken  to  choose  bull)s 
carefully,  seeing  that  they  have  a  sharp  focus — i.  e.,  cast  a  clear-cut  and 
22 


322  PHYSICAL   EXAMINATION 

not  a  hazy  or  foggy  shadow ;  so,  if  possible,  a  bulb  should  always  Ije 
seen  in  action  before  being  bought. 

The  stand  must  be  firm,  with  a  broad  foot,  and  capable  of  easy  and 
free  adjustment  to  any  angle  and  to  the  height  of  the  chest  of  the  tallest 
patient.  A  lead  screen,  in  view  of  what  we  know  of  the  effect  of  the 
Roentgen  ray  on  the  human  body,  is  an  important  essential.  The  lead 
should  be  one  sixteenth  of  an  inch  thick,  three  feet  high  by  two  feet 
wide,  and  mounted  in  a  firm  frame  on  an  adjustable  stand,  and  per- 
forated by  a  circular  four-inch  hole,  capable  of  being  diaphragmed  down 
to  various  smaller  diameters.  Such  a  screen,  placed  between  the  bulb 
and  the  patient,  and  about  two  inches  from  the  bulb,  cuts  off  all  rays 
save  those  transluminating  the  thorax;  it  protects  the  patient  as  well 
as  the  physician  from  harmful  effects. 

The  fluorescent  screen  should  not  be  of  the  type  usually  furnished 
by  supply  houses,  with  a  stereoscopelike  eye  piece  or  camera,  but  should 
be  a  large  sheet  of  cardboard,  sensitized  by  platino-cyanid  of  barium, 
sixteen  by  twelve  inches  in  size,  framed  in  wood,  and  with  a  handle  at 
the  middle  of  its  longest  side.  With  such  a  screen  the  whole  thorax  can 
be  seen  at  once,  and,  since  the  work  is  done  in  a  dark  room,  the  camera 
is  unnecessary  and  in  the  way. 

The  patient  is  best  examined  standing,  though  if  too  weak  he  may 
sit  on  a  stool ;  patients  so  weak  as  to  be  obliged  to  recline  are  usually 
not  in  a  position  to  leave  their  homes.  While  one  can  examine  through 
the  clothes,  metal  ornaments,  objects  in  the  pockets,  buttons,  etc.,  make 
so  much  trouble  that  it  is  better  to  examine  the  patient  stripped.  Tlie 
two  chief  directions  for  illumination  are  anteroposterior  and  po?-tero- 
anterior,  but  oblique  examinations  from  one  side  in  front  tc  the  other 
side  behind,  or  vice  versa,  must  not  be  forgotten,  especially  when  exam- 
ining the  contents  of  the  mediastinum.  Except  in  oblique  examina- 
tions, the  axis  of  the  rays  must  be  at  right  angles  to  the  transverse 
plane  of  the  patient's  chest  to  avoid  distortion,  very  slight  changes  from 
an  absolute  right  angle  producing  deceptive  appearances. 

The  patient  had  best  be  placed  about  two  feet  from  the  cathode,  or 
farther,  as  by  placing  him  too  close  to  the  tube  there  results  undue 
magnification  of  the  shadows.  The  most  useful  level  for  the  tube  is 
that  of  the  fourth  rib  at  the  sternum,  but  Holzknecht  advises  using  also 
a  higher  and  lower  level.  The  physician  should  be  in  the  dark,  with  his 
eyes  closed,  for  about  five  minutes  before  he  makes  the  examination, 
as  when  he  comes  directly  from  the  light  he  is  at  first  practically  blind, 
and  can  see  nothing  at  all,  whereas  if  he  gives  his  retina  time  to  become 
sensitive  in  the  dark,  he  will  be  able  to  see  and  study  the  shadow  pic- 
ture.    If  he  comes  from  bright  sunlight,  more  time  may  be  necessary. 

The  beginner  must  be  careful  not  to  conclude  quickly  that  a  shadow 


PHYSICAL   EXAMINATION  323 

is  pathologic,  but  must  consider  and  exclude  all  possible  sources  of  error, 
which,  as  noted,  are  numerous. 

A  regnlar  order  of  observation  should  be  followed,  noting :  First,  the 
comparative  size  and  shape  of  the  two  lung  areas;  second,  the  position 
and  size  of  the  heart;  third,  the  mediastinal  shadow  and  shadow  of  the 
roots  of  the  lung;  fourth,  the  motion  of  the  bases;  fifth,  the  clearness 
and  size  of  the  apices;  sixth,  an}'  shadows  in  the  body  of  the  lungs. 

The  picture  well  seen  and  fixed  in  the  memory,  the  physician  should 
record  it  at  once  on  his  chart,  reproducing,  as  closely  as  possible,  the 
extent,  shape,  density,  and  nature  of  the  sliadows,  and  any  bright  spots 
he  has  observed;  and  while  tliis  has  not,  of  course,  the  accuracy  of  a 
photographic  plate,  it  is  very  satisfactory  for  clinical  use,  and  enables 
one  to  keep  a  close  watch  on  decrease  and  increase  of  areas  of  shading. 

The  physical  examination  liaving  been  completed,  it  remains  for  the 
physician  to  draw  from  it  such  conclusion  as  it  justifies,  and  here  the 
writer  would  warn  not  simply  against  making  positive  diagnoses  in 
doubtful  cases  with  few  signs,  but  more  especially  against  the  far  more 
dangerous  and  harmful  fault  of  excluding  tuberculosis  because  the  first 
examination,  even  if  made  tliorouglily  and  carefully,  has  proved  nega- 
tive. Xo  clinician,  however  skillful,  can  be  positive  in  such  an  exclusion 
after  one  examination,  and  since  so  much  depends  on  it,  and  since  the 
patient,  comforted  by  such  an  assurance,  will  go  back  to  his  ordinary 
life,  it  is  wiser  to  tell  liim  tliat  no  positive  signs  were  found  and  lie  is 
probably  free  from  disease,  Imt  that  it  is  preferable  to  watch  him  for  two 
weeks  or  a  montli,  studying  his  temperature,  etc.,  and  reexamining  him 
before  giving  a  final  opinion.  After  such  a  course  one  can  feel  fairly 
sure  of  his  position,  though  faith  in  tlie  diagnostic  methods  of  modern 
medicine  must  never  cause  one  to  forget  that  in  this  life  the  absolute 
is  always  unattainable. 

Again,  one  is  often  tempted  or  urged  by  the  patient  to  give  a  prog- 
nosis after  one  examination,  but  the  longer  one  treats  tuberculosis  the 
more  wary  will  he  become  of  making  a  positive  prognosis.  Again  and 
again  one  sees  cases  that  have  impressed  us  favorably  develop  a  rapid 
and  destructive  process,  while  cases  which  seem  so  desperate  that  we 
risk  the  statement  that  they  will  live  at  most  two  weeks  or  a  month, 
will  survive  for  one  or  two  years,  to  be  claimed  by  the  Christian  Scien- 
tists as  cures  or  to  remind  us  that  prognosis,  at  best,  is  an  uncertain  art. 

The  study  and  combination  of  all  the  results  of  our  examination 
should  be  noted  carefully,  and  the  small  departures  from  the  normal, 
revealed  by  the  earlier  steps,  should  not  be  neglected,  but  should  be 
used  to  corroborate  the  findings  given  by  the  more  important  ones.  It 
is  desirable  also  to  record  on  the  charts  at  the  time  of  the  examination 
an  opinion  of  the  case  while  the  impression  made  on  the  mind  by  the 


324  PHYSICAL  EXAMINATION 

different  findings  is  fresh  and  sliarp,  for,  however  well  these  are  recorded, 
reading  them  over  will  never  reproduce  at  a  subsequent  date  the  clear 
impression  obtained  wlien  the  examination  was  just  finished. 

Finally,  a  note  of  warning  should  be  sounded  against  yielding  to 
the  temptation  when  tired  of  omitting  any  part  of  the  examination. 
Unquestionably,  in  some  cases,  certain  steps  can  be  omitted  without 
affecting  the  result,  but  one  can  never  tell  just  which  these  cases  are, 
and  there  is  not  one  step  which  in  certain  cases  is  not  of  the  greatest 
value.  Moreover,  by  commencing  to  omit  certain  steps,  one  enters  on 
an  easy  but  downward  path  tliat  will  surely  lead  into  careless  and  slip- 
shod work.    Facilis  decensus  Averni. 


CHAPTER   III 

DIAGNOSIS 

By  CHARLES  L.  MINOR 

In  these  days,  when  pathology  and  clinical  medicine  are  working 
together  so  effectiveh',  the  recognition  of  pulmonary  tulierculosis  need 
no  longer  be  postponed  until  the  disease  is  well  advanced,  and  for  the 
modern  physician  the  diagnosis  of  this  trouble  means  principally,  and 
practically,  its  early  diagnosis,  and  in  what  follows  I  shall  pay  atten- 
tion chiefly  to  the  discovery  of  the  trouble  in  its  incipiency. 

When  the  disease  has  reached  the  stage  which  justifies  the  use  of 
the  term  "  consumption,"  its  discovery  makes  no  demands  on  our  diag- 
nostic skill,  and  offers  little  assistance  to  our  therapeutic  efforts,  and 
the  physician  who  hopes  to  be  of  use  to  his  patient  must  remember  that 
his  results,  save  in  acute  or  galloping  cases,  will  be  in  direct  proportion 
to  the  earliness  of  his  diagnosis,  and  must  be  prepared  to  recognize  the 
trouble  in  its  very  beginning,  when  the  signs  and  symptoms,  unless 
closely  and  logically  studied,  can  be  so  ambiguous  as  to  be  confusing, 
and  when  he  will,  more  often  than  not,  be  deprived  of  that  absolute 
proof  which  can  be  given  only  by  the  discovery  of  the  bacillus  iu  the 
sputum. 

Such  an  early  diagnosis  is  often  a  difficult  task,  calling  for  the  most 
careful  clinical  work,  but  such,  fortunately,  has  been  the  advance  of 
diagnostic  methods,  and  such  the  improvement  in  medical  education, 
that  every  physician  Avho  is  willing  to  take  the  time  and  trouble,  and 
to  follow  a  proper  system  in  his  work,  should  be  able  to  make  the  diag- 
nosis, except  possibly  in  a  few  unusual  cases,  and  it  should  not  so  often 
as  it  is  be  left  to  the  specialist  to  discover  the  patient's  trouble. 

The  diagnosis  of  pulmonary  tuberculosis  is  a  result  of  the  careful 
study  of  the  facts  yielded  by  three  separate  procedures,  and  not  of  any 
one  of  these  alone — i.  e.,  a  history,  a  physical  examination,  and  a  study 
of  the  s}Tnptoms  and  clinical  course  of  the  case  for  a  longer  or  shorter 
period — and  can  be  fortified  by  the  use  of  certain  special  procedures, 
such  as  the  tuberculin  test;  but  while  we  can  thus  reach  practical  cer- 
tainty, it  need  hardly  be  stated  that  absolute  certainty  can  only  be 
attained  by  the  discovery  of  the  tubercle  bacillus  in  the  sputum.    While, 

335 


326  DIAGNOSIS 

however,  this  discovery  can  alone  make  an  absolute  diagnosis,  it  is  by 
itself  unable  to  make  a  complete  one,  and  if  such  a  complete  diagnosis 
is  desired  the  physician  must  make  use  of  each  of  tlie  procedures  to 
which  reference  has  been  made.  Moreover,  one  cannot  too  strongly 
dwell  on  the  folly  of  postj^oning  a  diagnosis  of  pulmonary  tuberculosis 
until  the  bacillus  is  discovered. 

While  it  appears  early  in  some  cases,  it  is  very  freiiuently  absent 
until  the  disease  is  well  advanced,  and  when  |)roper  methods  of  physical 
examination  can  make  us  morally  certain  of  the  nature  of  the  trouble, 
no  one,  therefore,  should  deprive  his  patient  of  the  advantages  of  early 
treatment  because  he  cannot  demonstrate  the  germ. 

The  physical  examination  yields  such  valuable  information  that  its 
findings  are  too  often  taken  as  final  and  sufficient  in  themselves,  and 
a  positive  diagnosis  made  from  them  alone.  This  is  an  unwise  practice, 
and  no  physician,  however  skillful,  should  in  a  doubtful  case  finally 
exclude  tuberculosis  after  one  examination,  or  until  he  is  able  to  study 
together  the  facts  gathered  from  a  full  and  searching  history,  a  thorough 
physical  examination,  and  a  study  of  the  symptoms  and  clinical  course 
of  the  case,  followed,  if  necessary,  by  a  reexamination.  Only  thus  can 
we  venture  to  exclude  tuberculosis,  or  sometimes  diagnose  it,  in  certain 
doubtful  cases  where  bacilli  are  absent,  and  these  are  the  very  cases  where 
it  is  most  important  that  we  should  be  sure  of  our  position.  Of  course, 
in  the  large  majority  of  cases,  a  positive  diagnosis  can  be  made  without 
so  much  effort. 

The  period  of  observation  is  chiefly  occupied  with  a  careful  study 
of  the  temperature,  which  should  be  taken  every  two  hours  during  the 
day,  and  also  on  one  or  two  nights,  to  reveal  possible  night  fever.  More- 
over, since  at  such  times  certainty  is  important,  it  may  be  necessary  to 
take  the  rectal  temperature  for  a  day  or  so  to  determine  its  relation  to 
the  mouth  temperature,  and  the  reliability  of  the  latter.  If  the  tem- 
perature proves  normal,  one  or  two  excessive  walks  should  be  ordered, 
which  will  often  reveal  otherwise  concealed  fever  (Penzoldt).  If  neces- 
sary, other  doubtful  symptoms  can  be  studied,  and  if  the  sputum  anal- 
ysis has  proved  negative  we  can  use  special  measures  to  demonstrate 
the  bacillus.  It  need  hardly  be  noted  that,  whatever  his  suspicions,  the 
physician  should  try  not  to  let  his  mind  be  prejudiced  in  favor  of  or 
against  any  special  diagnosis,  but  should  keep  it  open  to  conviction  in 
any  direction,  not  striving,  like  a  special  pleader,  to  make  out  a  case 
at  any  cost,  but,  like  the  true  scientist,  seeking  to  discover  the  truth 
from  the  facts,  however  at  variance  it  may  prove  to  be  with  his  pre- 
conceptions. 

Since  an  absolute  diagnosis  depends  on  a  discovery  of  the  bacillus 
in  the  sputum  or  stools,  this  will  be  considered  first. 


SPUTUM   EXAMINATION  327 

Sputum  Examination. — The  best  sputum  for  examination  is  usually 
that  raised  on  awakening,  coming  as  this  does  usually  from  the  lung 
proper.  When,  however,  the  patient  has  some  other  chief  time  for  clear- 
ing out  his  lungs,  it  should  be  collected  then.  In  early  doubtful  cases, 
when  little  or  no  sputum  is  raised,  the  patient  must  carry  around  with 
him  the  sputum  receptacle  at  all  times  so  as  to  catch  any  chance  expec- 
toration that  may  be  brought  up. 

In  the  morning  the  mouth  is  apt  to  be  contaminated  with  saliva, 
etc.,  so  that  it  should  be  well  rinsed  before  spitting,  to  avoid  any  unnec- 
essary contamination  of  the  specimen,  which  should  come  from  deep 
down  in  the  chest,  and  not  be  hawked  from  the  nose.  The  patient's 
statement  that  he  raises  nothing  should  not  be  accepted  too  quickly,  as 
often  by  training  he  can  be  taught  to  furnish  a  specimen  which  he  was 
unconsciously  swallowing. 

Furthermore,  the  fact  that  the  sputum  is  only  glairy  or  salivalike 
should  not  be  a  cause  for  rejection,  if  no  other  can  be  had,  as  at  times 
numerous  bacilli  can  be  found  in  such  mucoid  sputum. 

In  the  case  of  children,  who  cannot  raise  their  sputum,  but  swallow  it 
all,  it  maj-  be  necessary  to  administer  an  emetic  on  waking  and  search  the 
vomitus  for  masses  of  sputum,  and  this  may  also  be  necessary  in  difficidt 
cases  with  those  adults,  chiefly  women,  who  swallow  their  sputum.  It  has 
lately  been  suggested  that  the  fasting  morning  stomach  be  washed  out  for 
this  purpose. 

If  there  is  no  sputum,  some  advise  giving  potassium  iodid  for  a 
while  to  produce  bronchial  secretion,  but  the  very  harmful  effect  of 
this  drug  on  the  pulmonary  process,  which  I  have  frequently  had  oppor- 
tunity to  observe,  leads  me  to  think  this  an  unwise  procedure.  The 
drinking  of  warm  alkaline  waters  or  the  use  of  small  doses  of  ipecac  is 
harmless,  but  not  very  effectual.  Usually  three  or  four  expectorations 
are  sufficient,  but  in  negative  cases  it  may  be  necessary  to  save  all  the 
day's  sputum  and  concentrate  it  if  bacilli  are  to  be  found.  This  need 
not,  however,  be  resorted  to  until  frequently  repeated  examinations  have 
failed  to  demonstrate  the  bacillus,  and  it  need  hardly  be  noted  that  not 
one,  two,  or  even  ten  examinations  suffice  to  exclude  the  possibility  of 
tuberculosis,  but  that  we  are  justified  in  believing  the  process  very  prob- 
ably nontuberculous  if  very  many  repeated  examinations  are  negative. 

There  are  various  methods  of  concentration,  dependent  on  rendering 
homogeneous  the  total  mass  of  the  sputum  by  alkalies  or  digestive  fer- 
ments and  centrifugalizing  the  product.  The  writer  has  used  with  satis- 
faction the  method  recommended  by  Czaplewski,  who  considers  the  use 
of  the  stronger  alkalies  harmful  to  the  staining  qualities  of  the  germ. 
He  uses  twelve  per  cent  of  borax,  dissolved  in  hot  distilled  water  to  which 
an  equal  amount  of  boracic  acid  is  added.     This  is  filtered  while  warm, 


328  DIAGNOSIS 

and  the  excess  of  chemicals  allowed  to  crystallize  out.  Of  this  two  or 
three  parts  are  taken  to  one  part  of  sputum,  these  agitated  together  in  a 
tall,  stoppered  cylindrical  glass  till  homogeneous,  when  it  is  either  sedi- 
mented  for  twenty-four  hours  or  centrifuged. 

The  sputum  should  be  collected  in  water-tight,  wooden  boxes,  painted 
black  inside.  These  are  not  only  easily  burned  after  use,  unlike  glass  or 
metal  receptacles,  but  the  black  surface  and  the  wide  opening  permits 
picking  out  easily  the  particles  to  be  examined,  without  removing  the 
sputum  from  the  box,  which  is  both  dirty  and  dangerous. 

The  sputum  should  be  examined  within  a  few  hours  of  its  expectora- 
tion, as  otherwise  many  bacteria  which  often  liquefy  the  whole  mass,  and 
change  the  appearance  of  the  preparation,  can  develop.  Once  spread  and 
fixed,  the  cover-glasses  can  be  kept  for  a  more  convenient  time,  but  the 
greatest  care  must  be  taken  not  to  confuse  different  preparations,  which, 
where  many  samples  are  being  examined,  is  a  very  easy  matter. 

The  porcelain  dishes,  used  by  architects  for  mixing  their  water  colors, 
are  very  convenient  for  this  purpose.  The  names  of  the  patients  are 
written  in  the  different  compartments  with  a  skin  pencil,  and  the  cover- 
glasses  are  placed  accordingly,  the  whole  being  covered  by  a  bell  glass  to 
wait  until  a  convenient  time  for  examination.  If  boxes  with  black  bot- 
toms are  not  used,  the  sputum  must  be  spread  on  some  black  surface  to 
assist  us  in  selecting  proper  portions  for  examination. 

All  authors  speak  of  picking  out  the  small  rice  masses  or  cheesy  mat- 
ter, but  while  these  yield  very  large  numbers  of  germs,  they  are  never 
found  in  the  sputum  of  early  cases,  which  is  usually  mucoid,  or  mucopuru- 
lent, hence  we  have  to  satisfy  ourselves  in  such  with  picking  out  the 
thickest,  most  purulent  parts  of  the  specimen,  taking  from  each  a  small 
portion,  mixing  these  all  together  intimately  and  taking  the  final  lump 
from  the  mixture.  In  this  way  we  lessen  the  chance  of  taking  the  sample 
from  a  part  of  the  specimen  free  from  germs,  while  they  might  be  present 
in  some  other  portion.  Some  sputums  are  remarkably  tenacious  and 
rubberlike,  so  that  it  is  difficult  to  take  up  a  jjortion  on  the  platinum  loop, 
but  if  this  is  heated  the  sputum  will  adhere  to  it  easily.  The  portion 
taken  must  not  be  too  large,  else  it  will  make  a  thick,  dirty  specimen,  and 
will  ooze  out  between  the  cover-glasses  and  soil  the  fingers.  A  piece  the 
size  of  a  No.  2  shot  is  sufficiently  large.  The  sputum  can  be  spread 
either  on  a  cover-glass  or  on  a  glass  slide.  While  the  former  method  de- 
mands neater  work,  and  the  breaking  of  a  cover-glass  may  soil  the  fingers, 
it  yields  better  specimens.  With  a  proper  technic  the  fingers  need  never  be 
soiled,  or  the  glass  broken,  and  when  the  examination  is  over,  if  the  prep- 
aration is  not  to  be  preserved,  the  covers  can  be  burned  quickly  in  the 
Bunsen  flame. 

The  best  cover-glasses  to  use  are  those  of  medium  thickness,  seven- 
eighths  of  an  inch  square,  round  glasses  being  inconvenient  and  dirty  to 
spread.  The  covers  must  be  iT^rfectly  clean  and  fat  free,  which  is  best  ob- 
tained by  boiling  them  in  ten  per  cent  chromic-acid  solution,  washing  them 
well  in  running  water,  and  keeping  them  in  ninety-five  per  cent  alcohol. 


SPUTUM   EXAMINATION  329 

The  aim  in  spreading  is  to  get  a  thin,  even  layer  of  sputum,  so  that  the 
staining  and  decolorization  can  take  place  easily,  and  the  study  of  the  speci- 
men be  simplified.  In  order  to  accomplish  this,  place  the  proper  amount 
of  sputum  in  the  center  of  a  clean  cover-glass,  lay  on  the  second  cover- 
glass  so  that  the  corners  do  not  coincide,  and  by  gentle  pressure  between 
finger  tips,  combined  with  lateral  movements,  rub  out  the  sputum  to  an 
even,  thin  layer,  draw  the  covers  apart,  lightly  warm  them  both  over  the 
Bunsen  flame,  thus  drying  the  thinnest  portion  of  the  spread  only,  and 
continue  this  drying  until  the  sputum  is  evenly  spread  on  the  two  covers. 
The  sputum  may  be  rubbed  out  with  a  platinum  spatula  on  one  cover-glass, 
but  the  film  is  streaky,  of  varying  thickness,  and  we  get  one  cover  instead 
of  two  for  examination.  If  not  dried  fractionally,  the  spread  covers  must 
be  dried  in  the  air,  or  by  holding  them  well  above  the  Bunsen  flame  until 
perfectly  dry,  when  they  can  be  passed  rapidly  through  the  flame  three 
times,  more  passages  than  this  tending  to  burn  the  specimen  and  lessen 
its  staining  qualities. 

Many  stains  may  be  used,  but  Ziehl-Neelson's  is  the  best.  This  stain 
consists  of  a  mixture  of  one  part  of  a  saturated  alcoholic  fuchsin  and  nine 
parts  of  a  five  per  cent  aqueous  carbolic-acid  solution,  which  is  not  perma- 
nent, and  is  best  mixed  fresh  each  time.  The  cover-glass  is  covered  with 
stain,  and  it  is  then  held  over  a  Bunsen  flame,  until  the  fluid  steams  and 
sends  off  one  or  two  bubbles,  when  it  is  laid  aside  for  a  minute  or  two,  then 
drained  and  washed  thoroughly  in  distilled  water. 

The  decolorizing  of  the  specimen,  which  aims  to  remove  the  stain  from 
all  the  elements  of  the  sputum  except  the  tubercle  bacillus,  which  is  acid- 
resisting,  is  the  essential  feature  of  the  whole  staining  procedure.  Usually 
a  dilute  mineral  acid  is  used.  On  the  examination  of  urine  or  stools  where 
smegma  bacilli  may  be  present,  alcohol  must  be  used  in  the  decolorizing 
process,  either  with  or  after  the  acid,  but  in  sputum  work  an  aqueous 
solution  is  satisfactory. 

Twenty  per  cent  nitric  or  sulphuric  acid  is  usually  used,  the  latter, 
according  to  Czaplewski  ('00),  being  the  better,  but  these  strengths  must 
be  handled  carefully  to'  avoid  ovcrdecolorization,  though  when  their  use 
is  understood,  they  give  beautiful  results.  Other  decolorizers  are  Orth's 
hj'drochloric-acid  alcohol  (1  per  cent  in  70  per  cent  alcohol),  Ebner's  fluid 
(2.5  parts  hydrochloric  acid,  2.5  parts  sodium  chlorate,  and  100  parts  dis- 
tilled water  mixed,  to  which  add  500  parts  95  per  cent  alcohol),  and  sweet 
spirits  of  niter.  Pure  alcohol,  while  an  excellent  decolorizer,  is  too  slow. 
Whatever  solution  is  used,  decolorization  must  not  be  carried  too  far. 
The  cover-glass  should  be  so  placed  in  the  fluid  that  every  part  is  wet  at 
once,  and  should  be  removed  in  a  second  to  the  water,  which  brings  back 
the  red  color  which  was  changed  by  immersion  in  the  acid.  This  should 
be  repeated  until  the  proper  color  is  gotten.  The  color  to  be  aimed  at  is 
a  faint  pinkish-gray  tint  in  the  thin  parts  of  the  specimen.  Washing 
well  with  70  per  cent  alcohol  is  necessary  if  we  wish  to  exclude  smegma 
bacilli. 

For  counter-staining,  either  concentrated  aqueous  methylcne-blue  solu- 
23 


330  DIAGNOSIS 

tion  or  Loffler's  alkaline  methylene  blue  is  the  best ;  methylene  green  makes 
a  very  beautiful  contrast,  but  fades  out  very  quickly  in  daylight.  Methods 
which  combine  decolorization  and  counter-staining,  such  as  that  of  Gabbett, 
prevent  the  control  of  the  decolorizing  process,  hence  are  uncertain  and 
should  never  be  used.  The  counter-stain  should  act  only  one  or  two 
minutes,  and  the  cover-glass  should  then  be  well  washed  and  dried  under 
filter  paper  and  in  the  air  till  perfectly  dry,  as  dampness  will  cause  it  to 
cloud.  A  properly  prepared  cover-glass  should  show  a  smooth,  even  spread, 
evenly  stained  a  bright  blue,  with  no  thick  streaks  and  no  red  spots. 

The  specimen  is  mounted  in  immersion  oil  (B.  Fraenkel)  and  studied 
with  a  one-twelfth  inch  (2  mm.)  oil  immersion  lens,  a  No.  4  Zeiss  ocular, 
and  a  good  condenser.  Abbe's  being  very  generally  used  with  abundant  light. 

When  numerous,  the  bacilli  are  easily  found,  but  if  they  are  scanty 
the  search  is  often  a  long  one.  In  a  doubtful  case  a  diagnosis  should  never 
be  made  on  the  discovery  of  one  bacillus,  unless  it  is  absolutely  typical  in 
form,  size,  and  peculiarities.  If  the  result  is  negative,  the  sputum  must 
be  examined  frequently  and  carefully,  and  if  many  such  examinations  are 
negative,  we  should  homogenize  the  sputum. 

Hesse  puts  streaks  of  sputum  on  a  solidified  Hayden's  culture  medium, 
which  he  places  in  an  incubator,  at  blood  temperature,  and  in  five  or  six 
to  twenty-four  hours  bacilli  are  found  which  before  were  undiscoverable. 

By  means  of  animal  inoculations  bacilli  may  be  demonstrated  when 
none  can  be  found  by  the  microscope.  Intraperitoneal  injections  of  sus- 
pensions of  sputum  in  2  or  3  c.c.  of  sterile  saline  solution  are  made  in 
guinea  pigs,  which  are  killed  in  from  three  to  seven  weeks  and  carefully 
examined  for  anatomic  or  bacteriologic  evidence  of  tuberculosis.  Pure 
sputum  may  be  inserted  through  small  skin  incisions  in  the  groins, 
which  incisions  are  then  sealed  with  collodion.  The  inguinal  glands 
swell  in  from  eight  to  fourteen  days  in  positive  cases,  and  in  from  five 
to  seven  weeks  the  animal  is  killed  and  examined.  Unfortunately,  other 
bacteria  in  the  sputum  kill  a  large  number  of  the  animals  very  soon, 
especially  in  the  intraperitoneal  method,  hut  if  skillful  observation  is 
obtaina])]e  the  results  are  positive  and  valuable. 

In  the  case  of  children  or  others  who  swallow  their  sputum,  a  diag- 
nosis may  sometimes  be  made  by  an  examination  of  the  mucus  flocculi 
from  the  stools,  but  intestinal  tuberculosis  must  be  excluded  before  a 
diagnosis  of  pulmonary  tuberculosis  is  made. 

Smegma  bacilli  can  be  differentiated  by  the  fact  that  they  decolorize 
easily  in  alcohol,  unlike  the  tubercle  bacillus.  When  treated  with  a 
saturated  alcoholic  solution  of  methylene  blue  they  slowly  turn  blue, 
unlike  the  tubercle  bacillus,  having  been  deprived  of  their  fuchsin  by 
the  alcohol,  and  thus  being  able  to  take  up  the  counter-stain. 

History. — The  patient's  history  is  of  the  greatest  aid  in  making  a 
diagnosis  in  a  suspected  case  of  pulmonary  tuberculosis,  but  a  carelessly 


PHYSICAL   SIGNS  331 

taken  histor}'  is  worse  than  useless,  as  it  is  misleading.  F.  WolfE  ('94) 
places  the  history  ahead  of  the  physical  examination.  It  will  almost 
always  prove  that  the  trouble  had  its  beginning  long  before  the  patient 
suspected  himself  to  be  sick,  and  gives  information  as  to  his  family 
idiosyncrasies  and  constitution,  his  resistance  to  disease,  and  his  oppor- 
tunities for  infection. 

The  Family  History. — The  discovery  of  one  or  two  cases  of  tuber- 
culosis in  a  patient's  relatives  has  but  little  value,  but  a  tuberculous 
father  or  mother,  especially  if  they  were  sick  during  the  patient's  child- 
hood, or  tuberculous  brothers  or  sisters,  not  only  renders  probable  a 
decreased  resistance  to  the  disease,  but,  much  more,  demonstrates  oppor- 
tunities for  infection  in  early  life,  when  such  infection  is  easiest.  If 
many  relatives  have  died  of  the  disease,  it  is  naturally  both  diagnos- 
tically  and  prognostically  of  importance,  as  is  also  information  as  to  the 
course  which  the  disease  took  in  these  persons. 

The  childhood  history  should  show  home  and  school  conditions, 
opportunities  for  infection,  as  well  as  those  sicknesses  or  states  of  health 
which  favor  or  suggest  the  development  of  tuberculosis,  such  as  measles, 
pertussis,  scrofula,  otitis,  pleurisy,  pneumonia,  bronchitis,  delicacy  of 
constitution,  sickliness,  rickets,  etc.,  and  should  also  give  an  idea  of 
the  general  health  of  the  child. 

The  personal  history  can  demonstrate  not  only  unsuspected  chances 
for  infection  in  office,  store,  or  workshop,  where  the  abominable  Ameri- 
can habit  of  promiscuous  spitting  makes  itself  especially  evident,  but 
often  reveals  suspicious  past  sicknesses  which  masqueraded  at  the  time 
as  malaria,  neurasthenia,  or  dyspepsia,  or  will  reveal  the  occurrence  of 
ischiorectal  abscesses  or  pleurisies,  which  usually  mean  tuberculosis. 
Family,  financial  or  other  worries  should  also  be  inquired  into  if  the 
patient  is  willing  to  be  frank.  The  habits,  by  revealing  the  mode  of  life 
and  of  Avork,  dissipations  or  idiosyncrasies,  are  of  great  value,  and  we 
should  record  the  patient's  norm  as  to  appetite,  weight,  sleep,  etc.,  as 
standards  for  comparison. 

The  present  history,  at  least,  is  not  apt  to  be  neglected,  but  we  must 
ascertain  the  real  beginning  of  the  present  trouble  and  not  merely  the 
time  when  the  symptoms  became  so  marked  as  to  draw  the  attention 
of  the  inattentive  patient.  A  history  of  an  old  pneumonia  or  pleurisy,  for 
instance,  often  serves  to  explain  the  physical  signs  found  in  the  chest. 

The  status  prcBsens,  or  present  condition,  giving  tlie  existing  symp- 
toms, is,  of  course,  of  the  greatest  value  in  diagnosis,  and  for  further 
comparison  and  should  always  be  recorded. 

Physical  Signs. — The  facts  revealed  by  a  pliysical  diagnosis  have 
been  fully  dwelt  on  under  Physical  Signs.  Here  we  will  only  con- 
sider  briefly   their   relative   value   in   diagnosis.     No   physical   sign   in 


332  DIAGNOSIS 

and  by  itself  proves  tuberculosis,  and  every  sign  can  be  produced  by 
other  conditions;  hence  a  final  diagnosis  is  impossible  except  after  a 
synthesis,  not  simply  of  the  facts  yielded  by  the  physical  examination, 
but  of  those  gathered  from  the  history  and  a  clinical  study  of  the  case; 
the  practice  of  snap  diagnoses  based  only  on  a  brief  physical  exami- 
nation, leads  into  error.  Auscultation  and  percussion  always  show  less 
than  the  full  extent  of  the  trouble,  there  always  being  an  area  outside 
the  limit  of  a])normal  sound  where  the  disease  is  making  inroads. 

Inspection,  if  carefully  performed,  will  in  a  large  number  of  cases 
give  a  very  good  idea  of  the  chief  seat  of  the  troul)le  and  suggest  its 
nature,  but,  as  Babcock  ('07)  well  says:  "It  is  the  detection  of  very 
slight  differences  .  .  .  which  is  important."  Thus  pronounced  defor- 
mities, faulty  build,  long  flat  chests,  narrow  angle,  delicate  skin,  silky 
hair,  etc.,  have  value  chiefly  in  prognosis,  and  are  of  but  slight  use 
in  diagnosis.  Often  a  first  glance,  revealing  a  slight  flush  of  one  cheek, 
is  suggestive,  although  unilateral  pupillary  changes  cannot  be  relied 
on,  as  also  cannot  Thompson's  rod  line  on  the  gums.  In  acute  cases, 
cyanosis  of  the  fingers  without  clubl)ing  is  ominous,  as  is  an  ashy  gray 
pallor  or  widely  dilated  pupils. 

Very  slight  flattening  above  the  clavicle,  combined  with  slight  limi- 
tation of  motion  and  slight  shoulder  droop,  will  be  found  very  early 
in  the  disease.  Flattening  of  the  shoulder  outline  comes  soon  after  these 
alterations  as  muscular  wasting  begins,  and  is  accompanied  by  flatten- 
ing below  the  clavicle  and  of  the  upper  portion  of  the  pectoralis.  The 
more  pronounced  flattenings  occur  only  after  the  diagnosis  is  almost 
self-evident,  but  from  their  nature  one  can  at  times  suspect  the  pres- 
ence of  large  cavities,  or  more  especially  the  development  of  marked 
fibrosis.  In  the  former  case  we  will  at  times  find  localized  hollowings 
in  the  upper  one  third  of  the  chest  in  front,  as  in  large  shrinking  cavi- 
ties. In  the  latter  there  can  be  marked  contraction  and  shortening  of 
one  side  of  the  chest,  producing  concavity  of  its  lateral  outline  and 
drawing  the  shoulder  down  toward  the  hip  markedly. 

Palpation  is  not  of  great  value  in  diagnosis,  and  especially  in  early 
diagnosis,  but  a  distinct  increase  of  vocal  fremitus,  particularly  on  the 
left,  can  be  used  in  corroborating  other  signs.  Decrease  of  fremitus 
is  too  difficult  to  determine  accurately  to  be  of  value.  Small  areas  of 
increased  fremitus  at  the  bases  behind  or  in  front  are  useful  in  calling 
attention  to  slight  areas  of  consolidation  or  pleuritic  adhesion  bands, 
which  later  steps  will  verify.  The  discovery  of  enlarged  cervical  glands 
is  important,  and  if  excitement  from  the  examination  can  be  excluded, 
tachycardia  has  the  very  greatest  diagnostic  value  in  very  early  cases. 
Distortion  of  the  apex  beat  is  also  suggestive  of  fibrosis. 

Mensuration  is  much  more  reliable  prognostically  than  diagnostic- 


PHYSICAL   SIGNS  333 

ally,  though  the  discovery  of  an  undue  shrinkage  of  the  perimeter  on 
one  side  of  the  chest  by  the  lead  tape  can,  in  conjunction  with  other 
signSj  enable  us  to  decide  in  a  difficult  case  which  is  the  most  seriously 
affected  lung.  The  spirometer  findings  can  at  times  have  diagnostic 
value,  an  abnormally  low  vital  capacity  increasing  the  value  of  other 
findings,  but  usually  it  is  the  increase  or  decrease  from  time  to  time 
which  is  valuable,  and  then  rather  as  an  aid  to  prognosis. 

Percussion. — Percussion  changes  do  not  appear  as  early  as  do 
changes  in  auscultation,  but  by  very  careful  and  light  percussion  great 
diagnostic  assistance  can  be  gathered  in  very  early  cases.  Eeal  dullness 
is  never  an  early  change,  but  a  short  or  slightly  high-pitched  note,  or 
slight  tympany  appears  very  early.  In  incipient  cases  one  should 
be  careful  to  study  the  apex  in  the  three  vertical  zones  already  referred 
to,  as  one  of  these  may  be  impaired  while  the  others  are  still  resonant. 
For  this  reason,  if  for  no  other,  the  marking  out  of  the  apical  borders 
is  of  the  greatest  value.  The  posterior  aspect  of  the  apex,  no  less  than 
the  anterior,  should  receive  light  percussion,  heavy  percussion  often 
failing  to  reveal  the  changes  here  that  the  other  will  demonstrate. 
Percussion  directly  on  the  clavicle  must  also  not  be  neglected.  It  is 
important  to  hunt  carefully  for  small  isolated  areas  of  impaired  reso- 
nance, especially,  as  noted  elsewhere,  in  the  fourth  interspace  outside 
the  left  nipple  line,  or  between  the  scapula  and  the  spinal  column  low 
down,  but  we  must  be  careful  not  to  be  misled  by  undue  arching  of  the 
ribs,  producing  localized  dullness. 

Auscultation  is  recognized  as  the  most  accurate  and  delicate  of  diag- 
nostic methods,  and  on  it  is  placed  reliance  for  the  final  rounding  out 
and  completion  of  the  diagnosis. 

The  breath  changes  are  not  as  positive  diagnostically  as  are  rales, 
but  they  appear  earlier  and  combined  with  other  signs,  justify  a  posi- 
tive diagnosis  without  waiting  for  the  development  of  these  latter,  and 
if  the  physician  will  take  care  to  study  the  various  alterations  of  the 
respiratory  murmur,  he  will  not  have  to  wait  for  adventitious  sounds 
before  he  ventures  to  diagnose  the  trouble. 

The  sequence  of  these  various  alterations,  in  the  writer's  experience,  is 
(1)  rude  or  granular  breathing,  chiefly  inspiratory;  (2)  feeble  breathing; 
(3)  cogwheel  breathing;  (4)  harsh  vesicular  breathing  and  prolonged  ex- 
piration; (5)  vesiculobronchial  or  bronchovesicular  breathing.  Bronchial 
breathing  is  not  an  early  sign.  Transmission  of  the  heart  sounds  to  the 
right  apex  speaks  for  incipient  consolidation.  Grancher  ('90)  gives  the 
order  of  the  signs  as  (1)  feeble;  (2)  rude;  (3)  cogwheel;  (4)  bronchovesicu- 
lar; and  Turban  as  (1)  rude;  (2)  cogwheel;  (3)  harsh  vesicular;  (4)  feeble, 
and  (5)  bronchovesicular.  The  value  of  vesiculobronchial  breathing  or 
harsh  respiration  at  the  right  apex  is,  of  course,  less  than  when  found  at  the 


334  DIAGNOSIS 

left,  and  many  authorities  teach  that  in  young  girls  or  women  such  a 
change  has  no  diagnostic  value,  but  while  it  must  be  accepted  with  great 
caution  and  must  always  be  corroborated  by  other  signs,  its  presence 
should  cause  one  to  use  every  possible  care  in  seeking  for  more  positive 
signs  of  trouble.  The  subclavian  systolic  murmur  has  no  real  diagnostic 
value.  Changes  in  vocal  resonance  at  times  give  information  of  begin- 
ning consolidation  sooner  than  will  percussion,  and  we  should,  there- 
fore, be  careful  to  test  it,  chiefly,  however,  by  the  use  of  the  whispered 
voice,  small  isolated  patches  of  bronchophony  or  whispered  pectoriloquy 
revealing  such  patches  as  in  a  less  degree  can  increase  a  vocal  fremitus. 

Rales. — The  importance  of  rales  in  the  diagnosis  of  pulmonary  tubercu- 
losis does  not  need  to  be  insisted  on.  They  cannot  be  called  a  very  early 
sign,  the  process  being  diagnosticable  for  some  time,  and  often  for  a  long 
time,  before  they  appear.  Nevertheless,  they  must  always  be  sought  for 
with  the  greatest  care,  using  forced  breathing  and  cough,  as  well  as  those 
changes  of  position  (horizontal)  and  of  time  (early  morning)  which  favor 
their  development.  The  use  of  potassium  iodid  is  unwise,  but  the  use 
of  hot  alkaline  drinks,  or  of  ipecac  in  small  expectorant  doses,  is  harmless 
and  may  be  useful.  Creosote  preparations  or  ichthyol  or  alcohol  will  de- 
crease the  adventitious  sounds  so  that  in  doubtful  cases  these  drugs  must 
be  stopped  for  some  days  before  the  examination.  When  rales  first  appear 
they  are  usually  isolated  fine  crepitations  (dry  crackles)  not  different  from 
those  of  pneumonia,  except  in  their  scantiness,  or,  as  Babcock  thinks,  in 
being  less  sharp  and  crackling.  A  few  (often  only  one  or  two)  such  rales 
located  in  an  apex,  and  discovered  at  various  times  (persistent),  possibly 
disappearing  after  cough,  but  reappearing  after  some  hours  or  a  day,  are, 
perhaps,  the  strongest  diagnostic  sign,  though  after  an  attack  of  grip  an 
obstinate  spot  of  apical  catarrh  can  produce  just  such  signs  for  a  while. 
Even  when  not  at  an  apex,  persistent  rales,  accompanied  by  voice  changes, 
have  always  a  high  significance,  and  foreshadow  the  future  development 
of  an  area  of  involvement  (Sokolowski).  Indeed,  the  essential  difference 
of  the  signs  given  by  a  tuberculous  process  from  those  given  by  those  of 
any  other  catarrhal  process  is  their  persistence,  and  persisting  pulmonary 
signs  are  always  presumptively  tuberculous. 

Beginners  must  be  on  their  guard  against  mistaking  false  rales  of 
various  sorts  for  the  real  ones.  (See  Physical  Signs.)  Fine  sibilant 
rales  at  an  apex,  while  by  no  means  so  diagnostic,  are  also,  if  persistent, 
very  suggestive,  as  are  a  few  isolated  friction  sounds,  speaking  for  an 
apical  pleurisy.  With  the  appearance  of  fine  moist  rales  (moist  crackle, 
subcrepitant  rale)  the  ineipiency  of  the  process  is  passed,  and  as  it  ad- 
vances these  rales  increase  in  number  and  size,  until  they  gradually  develop, 
to  terminate  in  a  gurgle,  that  fatal  sign  which  usually  presages  the 
approaching  end.  Some  authors  consider  the  mucous  click,  an  isolated 
sticky,  moist  rale  of  medium  size  over  an  apex,  diagnostic,  but  while  it 
generally  speaks  for  tuberculosis,  it  does  not  occur  soon  enough  to  be 
classed  as  an  early  diagnostic  sign.  The  transient  atelectatic  rales  often 
found  at  the  bases  posteriorly  have  no  diagnostic  value. 


SYMPTOMS  AND   CLINICAL   COURSE  335 

The  laryngeal  examination  is  in  many  cases  of  the  greatest  value  diag- 
nostically.  When  slight  signs  in  the  lungs  have  excited  strong  suspicions 
of  tuberculosis,  the  discovery  of  a  tablelike  elevation  of  the  mucous  mem- 
brane of  the  posterior  commissure,  a  reddened,  swollen  arytenoid,  a  uni- 
lateral cord  paralysis  (if  aneurysm  can  be  excluded),  or  even  a  pale  and 
wrinkled  posterior  commissure,  will  transform  an  uncertainty  into  a  cer- 
tainty. 

Fluoroscopy. — The  fluoroscope  is  not  a  means  of  early  diagnosis  in  most 
cases.  At  times  it  will  show  a  contracted  shaded  apex  when  dullness  or 
marked  breath  changes  could  not  be  discovered,  but  such  findings  are  the 
exception. 

Limitation  of  motion  at  the  base  (Williams)  is  much  more  common 
and  is  valuable,  but  too  much  diagnostic  importance  should  not  be  placed 
upon  it.  In  the  early  diagnosis  of  bronchial-gland  enlargement,  however, 
the  fluoroscope  far  surpasses  all  other  methods,  and  even  if  this  in- 
strument is  not  regularly  used,  all  patients  in  whom  this  condition 
is  suspected  should  be  subjected  to  the  X-ray  for  verification  of  the 
diagnosis. 

Symptoms  and  Clinical  Course. — The  symptoms,  like  the  physical 
signs,  have  been  considered  in  detail  and  will  here  be  only  considered 
relative  to  diagnosis.  In  taking  the  history  they  should  be  inquired 
after  most  carefully,  avoiding  leading  questions  which  might  suggest  the 
desired  answer.  It  is  often  surprising  to  see  how  difficult  it  is  for 
patients  to  give  a  rational  and  clear  account  of  their  symptoms  and 
how  anxious  they  are  to  substitute  for  a  statement  of  facts  that  have 
come  under  their  own  observation,  the  diagnostic  terms  suggested  to 
them  by  some  friend  or  physician.  The  statement  that  a  patient  had 
"  grip "  should  never  be  accepted,  but  he  must  be  made  to  describe 
and  enumerate  the  symptoms  which  led  to  this  opinion,  and  very  often 
it  will  be  found  that  the  grip  was  an  exacerbation  of  a  preexisting 
tuberculosis,  that  a  typhoid  was  an  acute  attack  of  the  same,  or  a  malaria 
only  the  chills  and  sweats  of  a  pulmonary  process. 

Fever  will  not  usually  have  been  recognized  by  the  patient  in  incip- 
ient cases,  and  he  will  have  to  be  put  on  two-hourly  measurements  for 
from  two  to  four  weeks.  In  doing  so  a  reliable  thermometer  is  essen- 
tial. Great  assistance  will  be  derived  from  making  a  graphic  curve  of 
the  temperature  and  marking  red  lines  across  the  chart  at  97,  98,  and  99, 
which  makes  much  more  striking  rises  above  or  falls  below  these  points. 
A  two-hourly  record  during  the  day  should  always  be  insisted  on,  and 
in  suspicious  cases  night  measurements  at  eight,  twelve,  and  four  may 
be  necessary.  Thus  short-lived  rises  during  the  day  and  unsuspected 
night  fever  will  be  discovered.  It  is  probable  that  some  persons  normally 
have  a  temperature  above  or  below  the  usual  limits,  but  as  we  rarely  have 
an  opportunity  to  learn  the  patient's  normal  curve,  this  cannot  always  be 


336  DIAGNOSIS 

determined.  Persistent  afternoon  rises  above  99.2°  F,  are  very  suspicious 
if  the  patient  is  at  rest,  and  if  above  99.6°  F.  and  other  causes  can  be 
excluded,  it  can  be  ascribed  to  tuberculosis,  for,  as  Ruchle  aptly  says,  "■  a 
persistent  fever  for  \\hich  a  reasonable  cause  cannot  be  found  is  most 
probably  due  to  tviberculosis  in  the  system."  It  must  be  remembered, 
however,  that  all  men  have  some  rise  in  temperature  for  about  an  hour 
after  eating,  and,  therefore,  temperatures  taken  after  the  midday  meal 
must  be  over  100°  F.  to  be  of  value  (100.4°  F.,  Penzoldt).  The  frequent 
premenstrual  rise  in  women  must  not  be  forgotten  when  studying  slight 
temperatures. 

The  curve  in  tuberculosis  is  fairly  regular  in  early  cases,  and  marked 
irregularities  while  the  patient  is  at  rest  throw  some  suspicion  on  its 
tuberculous  origin.  The  temperature  may  be  normal  for  several  days 
together,  followed  by  periods  when  a  constant  slight  afternoon  temper- 
ature will  be  found,  but  two  or  four  weeks  of  observation  will  clear  this 
up.  The  rise  in  early  cases  rarely  comes  before  one  or  two  o'clock  in 
the  afternoon,  and  usually  lasts  but  a  short  time,  say  to  four  or  five 
o'clock,  or  even  less,  and  the  morning  is  marked  by  a  fairly  pro- 
nounced subnormal  temperature,  which  has  considerable  diagnostic 
value.  At  this  time  morning  temperatures  of  90°  F.  and  evening  rises 
to  99°  F.,  or  rarely  100°  F.,  are  the  rule,  and  greater  rises  would  sug- 
gest a  more  advanced  or  more  active  troul)le.  At  times  when  fever,  dis- 
coverable by  the  thermometer,  is  absent,  there  is  flushing  of  the  cheeks 
after  meals  or  on  excitement,  and  this  should  always  suggest  the  taking 
of  a  rectal  temperature.  When  tlie  temperature  is  pronounced,  diag- 
nosis by  physical  methods  is  usually  easy.  Patients  with  a  dilated 
stomach  and  retention  can  run  a  suspicious  temperature,  which  will 
entirely  disappear  on  the  correction  of  the  gastric  trouble,  and  this 
possibility  should  be  kept  in  mind  and  the  level  of  the  lower  border  of 
the  stomach  determined. 

Chills  in  early  cases,  unless  the  process  is  acute,  are  not  found,  and 
they  are  thus  of  value  as  suggesting  the  nature  of  the  case. 

Cyanosis  of  the  fingers  and  face  is  likewise  suggestive  of  acute 
trouble,  but  the  cyanosis  seen  in  childbed  fingers  has  no  diagnostic  value. 

Languor  is  a  common  and  early  symptom  and  a  very  valuable  one. 
It  is  too  often  explained  by  anything  else  rather  than  tuberculosis,  such 
as  neurasthenia,  overwork,  malaria,  etc.,  but  persistent  languor  should 
always  excite  attention. 

Anorexia,  when  combined  with  other  symptoms,  adds  weight  to  the 
suspicions. 

Early  tuberculosis  often  manifests  itself  as  dj/spepsia  and  a  per- 
sistent sense  of  fullness  and  weight  in  the  epigastrium,  belching,  dis- 
comfort, or  other  signs  of  fermentative  dyspepsia,  combined  with  wast- 


SYMFl^OMS  AND   CLINICAL   COURSE  337 

ing  and  fatigue,  are  of  great  importance  in  diagnosis.  Ischiorectal 
abscess  should  always  suggest  tuberculosis.  The  writer  has  never  found 
diarrhea  in  very  early  cases,  though  it  has  been  reported. 

Sweats  as  an  initial  symptom  are  rare.  They  were  present  in  one 
case  seen  by  the  writer  as  the  only  symptom,  but  were  finally  followed 
by  rational  signs. 

Dyspnea,  while  present  to  a  slight  degree  in  some  early  cases,  is 
not  of  value  diagnostically  except  in  acute  disseminated  cases,  when 
marked  dyspnea,  out  of  proportion  to  the  ph3fsical  signs,  would  suggest 
extensive  dissemination  of  tubercles.  In  a  later  stage  of  the  trouble  it 
is  almost  diagnostic  of  fibrosis. 

Emaciation. — A  persistent  loss  of  weight  is  at  times  the  first  symp- 
tom, and  always  arouses  the  anxiety  of  the  family  and  the  physician. 
In  such  cases  a  suspicion  of  tuberculosis  is  justified  if  no  other  cause 
is  found.  Babcock  ('07)  states  that  men  should  weigh  twenty-five 
pounds  per  foot  and  women  twenty-three,  and  that  any  reduction  below 
this  is  important  in  making  a  diagnosis.  The  method  of  Pignet  of 
estimating  the  corpulence — i.  e.,  the  height  in  centimeters  minus  the 
sum  of  the  chest  circumference  in  centimeters,  and  the  Aveight  in  kilos, 
which  should  yield  a  result  under  25 — is  considered  by  Meissen  a  useful 
means  of  estimating  the  patient's  resistance.  Figures  under  10  show 
a  very  strong  constitution,  those  between  11  and  15  a  strong  one,  those 
between  IG  and  20  a  good  one,  21  to  25  a  moderate  one,  26  to  30  a 
weak  one,  31  to  35  a  very  weak  one,  and  over  35  a  very  bad  one.  Papil- 
lon  gives  the  corpulence  as  the  relation  of  the  weight  in  hectogrammes 
to  the  height  in  centimeters,  which  he  states  must  in  girls  be  over  three. 

Hoarseness. — In  a  doubtful  case  a  persistent  hoarseness  or  clearing 
of  the  throat  suggests  weak  lungs  and  demands  a  laryngeal  and  pul- 
monary examination. 

Circulation,  Blood. — Tachycardia,  if  persistent  and  unaffected  by 
change  of  position  from  the  erect  to  the  recumbent  (Wells)  or  paroxys- 
mal on  slight  and  trivial  excitement  is  a  common  finding  in  tubercu- 
losis, and  a  very  valuable  one  in  diagnosis,  especially  in  the  absence  of 
fever,  a  pulse  running  persistently  over  90  to  100  being  suspicious. 
The  tension  of  the  pulse  as  a  diagnostic  factor  has  been  insisted  upon 
by  Papillon  especially,  but  while  hypotension,  comljined  with  tachy- 
cardia, is  suggestive,  too  many  other  conditions  can  affect  the  blood- 
pressure  to  make  it  of  great  value  by  itself.  The  morphology  of  the 
leucocytes  cannot  at  present  give  any  aid  in  diagnosis,  though  Arneth's 
work  (see  Blood)  promises  to  lead  to  valuable  developments  in  this  line. 

Pain. — Pain  is  not  of  great  diagnostic  value  in  early  tuberculosis, 
but  "  rheumatism  "'  of  the  shoulder  at  times  means  apical  pleurisy,  and 
a  burning  spot  in  a  supraspinous  fossa  or  pain  in  the  point  of  the  shoul- 


338  DIAGNOSIS 

der  on  cough  is  suggestive.  At  the  same  time  it  is  unwise  for  the  physi- 
cian to  belittle  the  importance  of  pain  in  regions  where  he  cannot  find 
any  physical  signs,  for  very  often  there  will  develop  later  at  these  sites 
evidences  of  trouble.  Fullness  and  pain  behind  the  sternum  is  at  times 
found  in  tracheobronchial  adenopathy.  Head's  painful  spots  have  not 
proved  of  value,  but  pain  on  percussion  over  the  apex  will  sometimes  be 
found  very  early,  and  a  sensitive  apex  is  always  highly  suspicious. 

Cough. — Cough  is  the  symptom  most  commonly  associated  by  the 
layman  with  this  disease,  and  is  rarely  absent  in  any  case.  It  appears 
very  early  and  remains  often  long  after  all  other  symptoms  have  gone. 
It  is  first  usually  dry,  and  more  of  a  "  hack  "  or  clearing  of  the  throat 
than  a  real  cough,  such  a  "  hack  "  as  already  noted  being  most  suspi- 
cious, but  often  scarcely  noted  by  the  patient.  Absence  of  cough  is  of 
much  value  in  excluding  tuberculosis,  and  a  persistent  cough  which 
gets  worse  in  summer  and  often  does  not  disappear  in  winter,  is  with 
few  exceptions  due  to  tuberculosis,  and  while  there  can  be  a  cough 
arising  from  irritation  of  the  pneumogastric  in  the  stomach  justifying 
the  term  "  stomach  cough  "  so  dear  to  the  layman,  this  explanation  should 
be  accepted  only  after  a  careful  stomach  examination.  Nervous  cough 
may  persist  for  long  periods,  but  does  not  tend  to  change  in  character, 
as  the  tuberculous  cough  always  does  with  a  lapse  of  time. 

Expectoration  will  often  be  absent  in  early  cases.  When  present  it 
strengthens  the  diagnostic  value  of  cough  as  a  symptom,  even  when  no 
bacilli  are  found  in  it. 

Hemorrhage. — Hemorrhage  from  any  cause  except  tuberculosis  is 
so  rare  that  it  is  astonishing  to  see  how  diligently  physicians  seek  to 
explain  it  as  coming  from  any  other  possible  cause,  a  practice  that  has 
been  disastrous  to  many  patients.  At  the  same  time,  hemorrhage  should 
not  be  regarded  as  of  tuberculous  origin  without  a  conscientious  effort 
to  exclude  other  causes,  notably  heart  disease  (mitral  stenosis  princi- 
pally, but  also  any  other  condition  which  can  produce  pulmonary  en- 
gorgement). The  expectorated  blood  in  early  and  dubious  cases  should 
be  examined  carefully  for  bacilli,  though  even  in  tul^erculosis  they  are 
not  always  found.  Brown  quotes  with  approval  the  method  of  Nattan- 
Larrier  and  Bergeron,  in  which  twelve  to  twenty  volumes  of  water  are 
added  to  the  blood  before  centrifuging  as  assisting  the  discovery  of  the 
germ.  Small  streaks  and  spots  of  blood  in  the  sputum  do  not  justify 
the  term  of  hemorrhage,  and  can  come  after  severe  cough  in  ordinary 
bronchitis,  but  should  cause  the  physician  to  keep  his  eye  on  the  patient. 

The  nose  and  throat,  on  whose  diagnosis  so  much  depends,  should  be 
examined  carefully  in  these  early  and  doubtful  cases  to  reveal  bleeding 
points,  and  disease  of  the  trachea  must  be  excluded,  as  also  other  local 
and  constitutional  conditions,  such  as  aneurysm,  heart  disease,  hemo- 


THE  TUBERCULIN  TEST  339 

philia,  etc.  In  incipient  cases  the  exclusion  of  the  gastric  origin  is  not 
difficult.  It  only  becomes  difficult  in  large  hemorrhages,  where  much 
blood  has  been  vomited  and  swallowed.  Cornet  says  ('07)  :  "However 
numerous  the  causes  may  be,  we  will  seldom  go  Avrong  when  the  patient 
feels  a  tickling  in  his  throat  and  brings  up,  with  a  violent  coughing  fit, 
foamy,  aerated  blood  (one  or  two  teaspoonfuls  or  much  more)  in  con- 
sidering the  case  tuberculous,  and  treating  it  as  such  until  the  contrary 
is  proven." 

Other  Diagnostic  Measures. — When  we  have  exhausted  all  the  usual 
steps  of  an  examination,  including  repeated  sputum  examinations,  and 
find  no  evidence  of  tuberculosis,  we  should  be  content  with  the  negative 
result,  it  being  neither  necessary  nor  wise  to  go  further,  but  in  some 
cases  the  history  or  the  signs  will  be  very  suspicious,  while  not  con- 
clusive, and  it  may  be  very  important  in  these  cases  to  find  some  other 
means  of  arriving  at  a  diagnosis.  Of  these  other  means,  the  first  and 
most  important  one  is  : 

The  Tuberculin  Test. — This  test,  as  a  means  of  completing  the 
diagnosis  of  a  doubtful  case,  has  been  before  the  profession  for  a  num- 
ber of  years,  but  only  recently  has  the  fear  of  this  preparation  which 
resulted  from  its  abuse  at  the  time  of  its  discovery,  calmed  sufficiently, 
as  the  result  of  a  painstaking  study  of  its  value  by  such  men  as 
Petruschky,  Turban,  Cornet,  Bandelier,  and  others  in  Germany,  and  in 
this  country  by  Trudeau,  Baldwin,  A.  C.  Klebs,  Otis,  and  others,  to 
allow  of  any  considerable  use  of  this  method  by  the  profession.  The 
neglect  was  unquestionably  due  to  a  fear  lest  it  might  tend  to  aggra- 
vate or  disseminate  the  process,  as  was  taught  by  Virchow,  but  while 
the  preparation  is  a  powerful  one,  and  needs  the  most  careful  hand- 
ling, the  work  of  innumerable  careful  observers  has  demonstrated  satis- 
factorily that  tuberculin^  carefully  used  in  proper  doses  in  properly 
selected  cases,  is  free  from  harmful  effects,  and  while  some  of  the  best 
workers  in  this  line  are  still  ultra-conservative  as  to  it  (Sokolowski, 
Meissen),  and  while  it  should  never  be  resorted  to  until  all  other  means 
of  making  a  diagnosis  have  failed,  it  is  safe  to  teach  that  no  strongly 
suspicious  case  should  go  undiagnosed  because  of  a  fear  of  the  danger 
of  tuberculin.  Osier  said :  "  An  important  point  is  its  harmlessness. 
I  remember  no  cases  in  which  injurious  results  have  followed  the  in- 
jection," and  this  is  to-day  the  view  of  such  a  majority  of  the  leading 
clinicians  that  no  physician  need  fear  to  recommend  its  use  to  his 
patients  if  properly  applied. 

The  question  is,  however,  does  a  positive  reaction  always  demonstrate 
the  existence  of  tuberculosis,  or  a  negative  one  always  exclude  it?  An 
absolute,  positive,  and  negative  diagnostic  measure  it  certainly  is  not. 
As  M.  Wolff  says,  "  an  absolutely  easily  applied  method  for  the  certain 


340  DIAGNOSIS 

determination  of  beginning  tuberculosis  .  .  .  would  be  almost  as  valu- 
able to  us  as  a  specific,"  but  a  method  to  be  useful  need  not  claim  to  be 
absolute,  and  the  test  yields  such  a  large  per  cent  (eighty-five  to  ninety 
per  cent)  of  reliable  results  as  to  make  it  of  the  greatest  value  in  diag- 
nosis. The  work  of  no  one  man,  however  extensive,  could  alone  serve 
to  decide  the  question  of  tlie  diagnostic  value  of  this  test,  but  only  by 
a  consideration  of  the  results  of  the  work  of  many  men  can  it  be 
answered. 

Since  1890  the  tuberculin  test  has  been  used  in  a  great  number  of 
cases  in  human  beings,  not  to  mention  its  use  in  cattle,  where  it  has 
a  greater  diagnostic  value  than  in  man  (over  ninety-seven  per  cent,  A. 
Fraenkel,  Nocard),  and  a  study  of  the  results  of  all  this  work  proves 
that  a  positive  reaction  to  the  tuberculin  test,  if  the  dose  is  not  too 
large,  justifies  the  diagnosis  of  the  existence  of  tuberculosis  in  the 
patient,  while  a  failure  to  react  casts  great  suspicion  on  the  tuberculous 
nature  of  the  process  if  we  can  exclude  old  healed  lesions  or  advanced 
trouble,  both  of  wliich  can  fail  to  react. 

Those  interested  in  the  statistics  should  refer  to  the  literature  of 
the  subject.  It  is  to-day  considered  that  from  eighty-five  to  ninety  per 
cent  of  cases  of  tuberculosis  will  react  positively,  suspicious  cases  in- 
cluded, and  that  very  nearly  a  hundred  per  cent  of  first-  and  second- 
stage  cases  which  are  demonstrably  tuberculous  will  react  to  the  test 
(Beck).  Brown  states:  "No  case  of  early  or  incipient  pulmonary 
tuberculosis  has  been  shown  to  fail  to  react  to  a  dose  of  0.01  c.c. 
(10  mgm.)  or  less  of  old  tuberculin."  Dunn  ('03),  of  Asheville,  wlio 
has  a  very  large  experience  with  tuberculin,  says :  "  The  test  is  a  safe, 
reliable,  practical,  and  justifiable  diagnostic  resource  in  those  cases 
in  wliich  its  use  is  indicated."  Turban,  who  has  had  a  very  large 
experience  with  it  for  a  number  of  years,  states  that  a  pronounced 
reaction  is  never  noted  in  the  healthy,  or  in  other  diseases,  but  this  is 
too  wide  a  statement,  and  despite  the  statement  of  Brown  that  "  no 
case  of  syphilis,  actinomycosis,  leprosy,  or  chlorosis,  which  reacted  to 
tuberculin,  has  been  proved  at  post  mortem  to  be  free  from  tubercu- 
losis," the  work  of  Otis  ('01)  and  others  justifies  the  belief  that  fresh 
syphilis  can  give  this  reaction,  and  even  such  enthusiastic  advocates  of 
tuberculin  as  Bandelier  and  Eoepke  admit  that  probably  syphilitics  will 
react.  Of  course,  it  must  be  remembered  that  modern  work  has  shown 
(Naegeli,  etc.)  that  a  large  number  of  people  have  a  latent  tuberculosis, 
and  that  thus  positive  reactions  in  those  having  other  diseases  may 
well  be  due  to  such  concealed  foci  in  the  system,  but  whether  such  foci 
exist  can  only  be  determined  by  post  mortems,  and  unless  such  are 
available  the  results  of  careful  clinical  work  must  decide  whether  the 
patient  has  tuberculosis  or  not,  and  a  positive  reaction  to  tuberculin. 


THE  TUBERCULIN  TEST  341 

unaccompanied  by  an}-  clinical  evidences  of  disease,  should  not  lead  us 
to  declare  the  patient  to  be  clinically  tuberculous,  but  should  demand 
careful  and  prolonged  study  of  the  case. 

While,  however,  tuberculin  is  not  an  absolute  proof  of  tuberculosis, 
the  fact  tliat  it  is  positive  in  eighty  or  ninety  per  cent  of  the  cases  makes 
it  an  invaluable  addition  to  our  diagnostic  armamentarium,  and  in  cases 
with  ver}'  dubious  signs  it  is  more  positive  than  anything  except  the 
discovery  of  bacilli  in  the  sputum,  and  the  physician  is  safe  in  assum- 
ing that  any  patient  whose  symptoms  and  signs  justify  the  use  of  the 
test,  reacting  distinctly  to  a  moderate  dose  of  tuberculin,  is  tuberculous. 
Likewise,  if  such  a  patient  fails  to  react  after  a  repetition  of  the  final 
dose,  he  is  justified  in  considering  that,  barring  a  possible  encapsulated, 
healed  focus,  the  patient  is  probably  free  of  tuberculosis. 

Te clinic. — While  any  of  the  various  preparations  of  tuberculin  can 
produce  the  reaction,  Koch's  old  tuberculin  is  now  universally  used  for 
diagnostic  purposes,  and,  as  in  diagnostic  work,  uniformity  of  proce- 
dure is  most  desirable,  the  use  of  any  other  product  cannot  be  considered 
wise.  The  old  tuberculin  is  now  made  in  excellent  quality  in  this  coun- 
try, and  for  a  long  time  was  made  and  most  generously  supplied  to  the 
profession  by  the  Saranac  Laboratories  under  Drs.  Trudeau  and  Bald- 
win. It  is  a  sirupy,  light-brown  fluid  which,  while  undiluted,  is  per- 
manent. BroAvn  wisely  draws  attention  to  the  fact  that  the  strength 
of  tuberculin  is  far  from  constant,  even  when  made  hy  the  same  process, 
so  that  it  should  always  be  carefully  standardized.  Dunn  ('03)  reports 
a  case  exemplifying  the  variability  of  different  samples  of  the  drug,  in 
which  5  mgm.  of  one  preparation  produced  neither  recognizable,  local, 
nor  general  reaction,  but  in  which,  after  the  proper  interval,  the  use  of 
2.5  mgm.  of  another  preparation,  which  had  shown  itself  unusually 
active,  gave  a  marked  general  reaction. 

For  use  it  is  diluted  under  strict  aseptic  precautions  with  0.5  to 
0.25  per  cent  carbolic  acid  in  distilled  water,  or  normal  salt  solution, 
using  pipettes  graduated  in  cubic  centimeters  and  tenths  of  a  cubic 
centimeter.  The  dilutions  needed  are  two :  one  of  1  per  cent  and  one  of 
^  per  cent,  and  these  will  last  for  a  week  at  least  if  kept  in  the 
dark.  The  1-per-cent  solution  contains  in  ^V  c.c.  (one  division  of 
the  usual  hypodermic  syringe  containing  1  c.c.)  1  mgm.  of  tuberculin 
and  the  ^V-pcr-cent  solution  contains  in  yV  c.c.  yV  nigm.  Thus,  by 
diluting  measured  quantities  of  the  fluid  with  the  carbolic-acid  solution, 
and  using  one  or  more  tenths  of  this  dilution,  we  can  get  any  dose  from 
Y^  mgm.  up  to  10  mgm.,  hence  no  others  are  needed  for  diagnostic 
purposes.  For  example,  in  preparing  a  dose  of  yf^j-  mgm.  we  suck  yV 
of  a  cubic  centimeter  of  the  yV-p^r-cent  solution  into  the  syringe  (one 
division),  this  equaling  y*g-  mgm.  of  tuberculin,  and  dilute  it  with   j-^^ 


342  DIAGNOSIS 

c.c.  of  a  carbolic-acid  solution,  each  division  of  the  mixture  therefore 
equaling  ^^  mgm.  of  tuberculin,  and,  of  course,  five  divisions  contain 
the  YT  0"  nigm.  of  it.  The  syringe  must  be  sterile,  and  is  best  kept  in 
1-per-cent  carbolic  water,  or,  if  made  of  glass,  in  alcohol.  The  needle 
should  be  boiled  before  use. 

The  usually  chosen  site  for  tlie  injection  is  under  the  angle  of  the 
scapula,  but  any  convenient  region  can  be  used.  The  site  is  cleaned 
with  alcohol.  The  writer  prefers  driving  the  needle  vertically  into  the 
muscles  up  to  -its  socket,  which  avoids  all  veins  and  is  less  painful  than 
the  subcutaneous  method.  While  cleanly  injection  prevents  any  abscess 
formation,  a  local  reaction  around  the  site  of  injection — i.  e.,  some  red- 
ness and  tenderness  and  stiffness — occasionally  occurs,  but  never  goes 
any  further  than  this.  Some  have  advocated  the  patient's  going  to  bed 
for  twenty-four  hours  after  the  injection,  but  this  is  not  necessary  unless 
strong  reaction  occurs,  although  the  next  day  should  be  spent  quietly 
in  a  reclining  chair. 

Since  nervous  patients  can  very  easily  produce  the  symptoms  which 
they  are  led  to  anticipate,  it  is  important  in  diagnostic  cases  not  to 
let  them  know  what  you  expect.  Three  days  or  a  week  preceding  the 
injection  should  be  given  up  to  a  two-hour  study  of  the  temperature 
and  a  record  made  of  the  exact  pulmonary  findings,  for  it  is  only  by 
a  comparison  with  the  norm  that  the  method  has  value.  After  the 
injection  the  temperature  must  be  taken  two  hourly  in  the  daytime  for 
thirty-six  hours,  and  the  chest  watched  for  local  signs. 

Dosage. — There  is  considerable  difference  of  opinion  as  to  the  best 
doses,  but  fair  uniformity  as  to  its  maximum  and  minimum  limits. 
Koch  originally  recommended  an  initial  dose  of  1  mgm.,  followed  in 
two  days  by  5,  and  this  by  10,  with  a  repetition  of  the  last  dose,  if 
negative.  Turban  uses  0.5  mgm.,  2  mgm.,  5  mgm.;  Cornet,  1  mgm.,  3 
mgm.,  5  to  G  mgm. ;  L.  Brown  recommends  ^  mgm.,  1,  3,  5,  and  8  mgm. 
M.  Wolff  begins  with  yL-  mgm.,  then  -^  mgm.,  then  1,  2,  5,  and  10  mgm. 
Eoepke  uses  -^^,  1,  and  5.  Petruschky,  in  young  people  or  children,  ad- 
vises -jV>  tV>  2'  ^"^^  5  mgm.  Loewenstein  and  Kauffmann  ('06)  advocate 
a  different  plan,  using  a  dose  of  -f-^  mgm.,  repeated  at  three-day  intervals, 
four  doses,  and  then,  if  necessary,  though  this  they  think  will  rarely 
be  the  case,  2,  5,  and  10  mgm.  The  hypersusceptibility  created  in  the 
body  by  one  dose  is  the  fact  on  which  they  rely  in  the  use  of  these 
repeated  small  doses,  believing  that  in  this  way  the  small  doses  are 
raised  to  the  value  of  larger  ones.^  Others  have  suggested  that  such 
repeated  small  doses  might  create  an  immunity  and  so  defeat  the  test, 

'This  hypersusceptibility  is  the  same  as  that  prochiced  in  the  body  by  the 
tubercle  bacillus  and  its  products,  on  which  the  tuberculin  test  depends. 


THE  TUBERCULIN  TEST  343 

hence  this  method  has  not  met  the  approval  of  most  experts  in  this 
work.  There  is  certainly  no  harm,  and  there  are  many  advantages,  in 
a  moderate  initial  dose,  and  the  writer  favors  y%  nigm.  for  a  begin- 
ning dose,  followed  by  1,  2,  and  5  mgm.,  which  will  usually  be  satis- 
factory; while  if  this  is  negative  and  the  patient  is  strong  we  can  use 
an  8  or  10  mgm.  dose,  repeated  once.  More  than  10  mgm.  should 
never  be  used.  If  one  dose  produces  a  mild,  indefinite  reaction,  the  same 
dose  should  be  repeated  in  two  days,  when  it  will  frequently  result 
positively  and  distinctly.  Koch  considers  a  strong  reaction,  follow- 
ing a  repetition  of  the  dose,  as  especially  characteristic,  and  believes 
that  this  may  be  regarded  as  a  quite  infallible  sign  of  the  presence  of 
tuberculosis. 

In  view  of  the  fact  that  the  reaction  can  be  delayed  for  thirty  hours, 
or  even  more,  it  is  essential  that  two  days  elapse  between  the  doses,  and 
some  authors  advocate  an  interval  of  three  days.  It  should  never  be 
forgotten  that  reaction  to  tuberculin  is  not  limited  to  the  tuberculous 
if  the  dose  be  large  enough,  the  tuberculous  person  differing  from  the 
normal  not  in  reacting  but  in  reacting  to  small  doses,  and  it  is  there- 
fore of  the  utmost  importance  that  the  largest  diagnostic  dose  shall 
never  be  large  enough  to  produce  a  reaction  in  a  normal  person.  Koch 
has  set  this  maximum  at  10  mgm.,  and  while  reactions  will  usually  be 
obtained  with  smaller  doses,  most  authorities  are  united  in  considering 
that  a  reaction  to  10  mgm.  will  not  occur  in  the  normal  man. 

The  usual  tiine  for  injection,  and  that  recommended  by  Koch  and 
others,  is  as  late  in  the  evening  as  possible,  so  that  any  possible  tem- 
perature rises  in  the  night  should  not  be  missed,  but  Bandelier  and 
Roepke  ('08),  who  have  had  a  very  large  experience,  advise  injections 
between  eight  and  ten  in  the  morning,  since  most  reactions  come  in 
six  to  eight  hours.  The  dosage  in  children  must  be  smaller  than  in 
adults  by  ^  to  j\.  usually  yV  nigm. ;  j\,  1,  and  3  mgm.  are  advisable. 
Koch  is  very  particular  in  insisting  on  ascertaining  the  normal  tem- 
perature of  the  patient  before  the  beginning  of  the  test,  and  believes 
that  the  temperature  must  not  go  over  99.1°  F.  in  the  afternoon. 
Brown,  and  also  W.  L.  Dunn,  believe  that  100°  F.  is  not  too  high  a 
limit  in  the  hands  of  one  experienced  with  the  method. 

Tlie  Reaction. — This  is  local  and  general.  The  former  is  the  specific 
feature  of  the  reaction,  and  is  due  to  congestion  around  the  tuberculous 
focus,  probably  resulting  (Citron)  from  the  combination  of  the  tuber- 
culin in  the  blood  and  the  antibodies  in  the  focus. 

If  the  lesion  is  visi1)le  (skin,  larynx)  this  reaction  is  manifested  by 
redness  and  swelling,  and,  if  concealed,  l)y  an  increase  of  physical  signs, 
the  result  of  the  engorgement  and  swelling  around  the  lesion.  Turban 
considers  the  signs  of  a  local  reaction  in  the  lung  as  the  most  valuable 


344  DIAGNOSIS 

part  of  the  test,  and  watches  the  patient  daily  for  the  development  or 
increase  of  dullness,  breath  changes,  and  especially  rales,  but  while 
such  local  signs,  when  found,  are  very  valuable,  they  are  often  absent 
and  are  not  essential  to  a  diagnosis.  The  cough  and  sputum  are  natu- 
rally also  increased,  and  bacilli  which  have  been  absent  may  appear, 
hence  Turban  advises  the  careful  collection  of  all  the  sputum  during 
the  test. 

The  general  reaction  is  not  specific,  since  sufficiently  large  doses  of 
tuberculin  produce  a  reaction  in  normal  people.  It  is  manifested  by 
fever  and  constitutional  symptoms,  and  is  not  different  from  the  effects 
of  any  other  bacterial  toxins  on  the  human  system.  The  patient  feels 
badly,  complains  of  headache  and  chilly  sensations,  or  has  a  definite 
chill,  his  joints  ache,  he  feels  weary,  loses  appetite,  and  has  a  rapid 
pulse,  and  at  times  will  develop  nausea  and  vomiting.  If  tuberculous 
glands  are  concealed  in  the  body  they  will  frequently  be  revealed  in 
this  way.  The  writer  has  known  areas  of  localized  tenderness  in  the 
abdomen  to  suggest  probable  intra-abdominal  glands.  The  temperature 
rise  may  be  slight,  moderate,  or  great,  but  usually  runs  from  100°  plus 
to  103°  F.  (see  accompanying  charts). 

A  reaction  with  temperature  not  over  100.5°  F.,  and  with  few  con- 
stitutional symptoms,  is  called  mild,  one  in  which  the  temperature  runs 
from  100.5°  to  102°  F.,  with  more  pronounced  symptoms,  is  considered 
medium,  and  one  with  fever  above  this  point  accompanied  by  marked 
prostration  is  considered  severe.  A  rise  to  less  than  100°  F.  (Roepke, 
100.4°  F.),  unless  supported  by  a  local  reaction,  when  a  rise  of  1°  F.  is 
enough,  should  not  be  considered  diagnostic,  but  should  call  for  a  repe- 
tition of  the  dose. 

While  the  reaction  may  begin  in  four  hours  or  be  postponed  for  thirty- 
six,  most  reactions  occur  in  from  six  to  eight  hours,  or  slightly  more, 
and  persist  for  from  six  to  twelve  hours,  then  disappearing  rapidly,  and 
leaving  behind  only  a  sense  of  fatigue  for  a  little  while,  until  by  the 
third  day  the  patient  is  himself  again,  and  often  feels  better  than  be- 
fore. Very  early  (under  four  hours)  or  very  late  reactions  (after  forty 
hours)  should  be  excluded  from  consideration,  as  not  resulting  from 
the  injection.  In  the  very  nervous,  whose  excital)ility  can  give  them 
slight  rises,  it  is  at  times  necessary  to  make  the  first  dose  of  sterile 
water,  or  five-per-cent  carbolic  solution,  to  exclude  this  "nervous  tem- 
perature." A  positive  and  distinct  reaction,  if  accompanied  with  other 
suspicious  signs  or  symptoms,  justifies,  as  already  said,  a  diagnosis. 
To  quote  Petruschky  ('00),  one  of  the  most  faithful  students  of  this 
subject,  "  if  several  times  typical  reactions  follow  injections  (chiefly 
on  the  next  day)  when  between  and  before  the  temperature  is  normal, 
we  can  with  certainty  conclude  that  the  patient  is  tuberculous." 


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Fig.    78. — Tuberculin    Injection        Fig.      79. — Mild     Re.\ction     After 


WITH  Xeg.\tive  Result.  Slight 
reaction  after  second  injection. 
No  rise  after  third  and  fourth. 
Diagnostically  negative. 


Fourth  Injection.  Local  reac- 
tion in  right  lower  lobe.  Bacilli 
in  sputum  during  reaction.  Diag- 
nosis: Tuberculosis  right  apex  and 
right  lower  lobe. 


Fig.  80. — Mild  Re.\ction  After  Sec- 
ond Injection  (1  mg.).  Stronger 
reaction  after  repetition  of  same 
dose. 


Fig.  81. — Active  Reaction  After 
Third  Injection  (o  mg.).  Rapid 
rise  on  day  of  injection.  Fall  by 
lysis  in  course  of  three  days.  Di- 
agnosis: Tuberculosis  upper  right 
lobe.     Local  reaction. 


Fig.  82. — After  First  Injec- 
tion Pseudo-reaction  from 
Parulis.  After  second  in- 
jection (same  dose)  no  reac- 
tion. After  third  injection 
(1  mg.)  moderate  reaction. 
Tuberculosis  of  both  apices. 


Fig.  83. — Tuberculin  Diagnosis  in  Neu- 
rasthenia. Fluctuating  temperature 
(over  98.6°  F.)  before  injections.  Con- 
trol injection  with  water;  no  distinct 
reaction,  normal  conditions.  After  first 
tuberculin  injection  mild  reaction;  on 
repetition  stormy.  Local  reaction  at 
left  apex. 


Note. — The  temperature  charts   here  given  are  from   Bandclier  and  Roepke 
('08),  transposed  into  Fahrenheit  degrees. 

345 


346  DIAGNOSIS 

Contraindications. — However  useful  this  test  may  be,  its  indiscrimi- 
nate use  is  to  be  discouraged,  and,  as  already  noted,  it  should  only  be 
resorted  to  when  every  means  of  making  a  diagnosis  has  been  used,  and 
even  then  it  should  not  be  applied  unless  the  case  seems  strongly  sus- 
picious. Further,  the  temperature  must  not  be  higher  than  99.2°  F. 
Recent  acute  diseases  in  the  chest  or  elsewhere  are  a  contraindication, 
or  any  hemorrhages  within  the  month.  Heart  disease,  if  the  heart  be 
compensated,  need  not  prevent  its  use,  but  if  uncompensated  or  of  a 
severe  form,  it  is  a  contraindication.  Nephritis  and  epilepsy  are  also 
regarded  as  contraindications. 

The  tuberculin  test  in  itself,  and  unsupported  by  anything  else,  does 
not  justify  the  diagnosis  of  a  case  as  clinically  tuberculous,  as  it  may 
be  caused  by  an  inactive  encapsulated  focus,  and,  as  Hamman  ('08) 
has  well  said,  "the  tuberculin  reaction  acquires  significance  only  as  a 
part  of  the  general  clinical  picture,"  or,  to  quote  Sokolowski  ('06), 
"  Excluding  the  appearance  of  bacilli  we  know  no  single  pathognomonic 
sign  for  this  disease;  our  diagnosis  must  rest  upon  a  consideration  of  all 
symptoms,  their  critical  weighing  and  the  exclusion  of  all  those  processes 
which  could  produce  the  existing  condition  in  the  patient,"  and  this  test 
should  be  regarded  as  an  addition  to,  rather  than  as  a  substitute  for, 
regular  measures,  and  to  l)o  used  only  when  distinctly  indicated. 

Modifications  of  the  Tuberculin  Test. — Among  the  various  causes 
which  have  served  to  delay  the  general  adoption  of  the  tuberculin  test 
is  the  unfamiliarity  of  the  profession  with  its  technic,  which  is  really 
very  simple.  As  a  consequence,  the  announcement  in  1907  by  von 
Pirquet,  Wolff-Eisner,  and  Calmette  of  new  and  simple  modifications 
of  this  test  have  awakened  very  general  interest. 

Von  Pirquet's  reaction,  better  called  the  cutaneous  reaction,  is  pro- 
duced when  the  skin  is  aljraded  through  one  or  two  drops  of  a  twenty- 
five-per-ccnt  solution  of  old  tuberculin  (one  part  tuberculin,  one  part 
five-per-cent  carbolic  glycerin,  two  parts  normal  salt  solution),  which 
is  left  in  place  for  a  few  moments,  and  then  ruljljcd  off  (it  has  been 
shown  that  rubbing  of  stronger  solutions  without  abrasion  is  sufhcient, 
Ligniere's,  '07;  ]\Ioro,  "08).  In  from  twenty-four  to  forty-eight  hours 
a  zone  of  light  pinkish  redness,  about  half  an  inch  in  width  and  ac- 
companied by  swelling,  api)ears,  and  finally  a  papule  forms.  These 
signs  disappear  in  about  eight  days  and  leave  behind  some  temporary 
discoloration  of  the  skin. 

The  ophthalmic  reaction,  better  called  the  conjunctival  reaction,  which 
was  first  observed  after  the  application  of  stronger  solutions  (ten  per 
cent)  by  Wolff-Eisner,  was  clinically  applied  and  modified  by  Calmette. 
It  is  produced  when,  in  tuberculous  subjects,  a  one-per-cent  solution  of 
dry  tuberculin  (alcohol  precipitate)  in  sterile  water  is  dropped  into  the 


MODIFICATIONS  OF   THE  TUBERCULIN   TEST  347 

conjunctival  sac.  In  the  normal  man,  according  to  Caluictte,  this  has 
no  result,  or  at  most  a  very  slight  temporary  reddening,  but  in  the  tuber- 
culous, shortly  after  the  application  the  patient  feels  a  sense  of  itching, 
burning,  and  smarting  in  the  eye.  To  quote  Calmette's  original  de- 
scription ('07)  : 

Five  hours  after  the  instillation,  at  times  in  three  hours,  all  the  tuber- 
culous develop  a  marked  congestion  of  the  palpebral  conjunctiva;  it  be- 
comes bright  red  and  shows  a  more  or  less  intense  edema.  The  caruncle 
sw^ells,  reddens,  and  is  covered  with  a  slight  fibrinous  exudate.  The  vas- 
cular injection  increases  by  degrees  and  is  accompanied  by  lacrymation. 
At  the  end  of  six  hours  the  fibrinous  secretion  becomes  more  abundant 
and  collects  in  filaments  in  the  inferior  conjunctival  cul-de-sac.  The 
maximum  intensity  of  the  reaction  is  between  six  and  ten  hours.  The 
patient  complains  of  no  pain  but  only  a  little  discomfort,  with  a  sensa- 
tion of  a  slight  swelling,  and  some  trouble  with  vision,  in  proportion  to 
the  degree  of  exudate.  There  is  no  chemosis.  The  course  of  the  rectal 
temperature  is  not  sensibly  altered.  ...  In  children  at  the  end  of  eighteen 
hours,  in  adults  at  the  end  of  twenty-four  to  thirty-six  hours,  the  phe- 
nomena of  congestion  decrease  and  finally  disappear.  In  healthy  non- 
tuberculous  people  the  instillation  of  tuberculin  is  without  any  result. 
At  most  one  notes,  in  from  one  to  three  hours  afterwards,  a  slight  red- 
ness, which  disappears  quickly  and  is  not  accompanied  by  any  fever  or 
lacrymation. 

Further  use  of  this  method  by  many  physicians  has  demonstrated 
that  this  description  is  excellent  if  we  refer  to  mild  or  moderate  reac- 
tions, but  that  severe  reactions  occur  at  times  which  can  greatly  exceed 
this  picture  in  intensity.  The  pain  and  photophobia  can  be  extreme, 
and  the  swelling  so  intense  as  to  close  the  eye. 

Calniette,  in  his  modification  of  the  test,  reduced  the  maximum  dose 
to  one  per  cent,  which  it  is  now  recognized  should  not  be  passed,  as, 
like  the  tuberculin  test,  a  sufficients  strong  dose  can  produce  reaction 
in  anyone,  and  the  effect  of  strong  doses  can  be  very  severe. 

Collin,  of  Berlin  ('08),  an  oculist,  has  dwelt  on  the  possible  dangers 
to  the  eye  from  this  tost,  and  calls  attention  to  the  necessary  uncertainty 
of  the  dosage,  and  other  physicians  and  oculists  have  reported  very  severe 
conjunctivitis,  ulcerations,  and  keratitis,  and  Serafini  ('07)  even  an 
abscess. 

To  avoid  possible  severe  reactions,  Comby  ('07)  recommended  the 
use  of  0.5  per  cent  solution  for  this  reason,  and  Baldwin  ('07)  would 
reduce  this  to  0.35  per  cent  for  the  initial  dose. 

The  instillation  is  best  made  in  the  morning,  so  that  the  eye  can 
be  examined  from  time  to  time  during  the  day  for  signs  of  reaction. 
It  is  convenient  to  use  a  delicate  dropper,  yielding  a  small  and  uni- 


348  DIAGNOSIS 

form  drop.  The  drop  is  deposited  in  the  conjunctival  sac  of  one  eye 
and  carefully  distributed  around  so  as  not  to  be  promptly  winked  out. 
Briggs  has  suggested  that  the  rapidity  with  which  the  lacrymal  duct 
removes  secretion  from  the  eye  in  some  people  is  so  great  as  possibly 
to  affect  the  results  of  the  test,  and  he  advises  position  directed  to  pre- 
vent this,  a  suggestion  which  seems  to  me  worthy  of  consideration.  If 
in  one  day  there  is  no  reaction,  instill  into  the  other  eye  the  next 
stronger  solution.  A  0.5  per  cent  solution  for  the  first  dose,  and  1 
per  cent  for  the  second  dose  is  best;  the  writer  has  not  found  the  0.35 
per  cent  solution  to  produce  reactions.  The  use  of  the  other  eye  for 
the  second  dose  is  important,  as,  even  in  normal  people,  a  certain  degree 
of  hypersusceptibility  is  created  in  the  eye  by  the  first  dose,  and  in 
the  tuberculous  in  the  other  eye  as  well,  hence  a  false  reaction  might 
occur  in  the  nontuberculous  with  the  second  dose  if  the  same  eye  is 
used  twice.  T'nlike  the  tuberculin  reaction,  tliere  is  no  effect  on  the 
temperature  in  the  large  majority  of  cases,  though  Wolff  ('08)  and 
Cohn  ('07)  have  reported  cases  where  this  occurred,  and  in  Cohn's 
case  there  was  both  local  and  gland  reaction  and  general  phenom- 
ena. Baldwin  ('07)  advises  classifying  the  results  as:  first,  nega- 
tive; second,  doubtful,  in  which  tliere  is  slight  reddening  of  the  caruncle; 
third,  positive  -|-,  distinct  pali)ebral  edema  and  secretion;  fourth,  posi- 
tive -| — |-,  ocular  and  palpebral  edema,  with  well-marked  secretion;  and 
fifth,  positive  -| — | — \-,  deep  injection  of  entire  conjunctiva,  with  edema 
of  lids,  photophobia,  and  secretion. 

The  contraindications  are  the  presence  of  any  ocular  disease,  espe- 
cially conjunctivitis,  and  more  especially  what  has  been  called  the  stru- 
mous diathesis.  In  a  patient  with  this  diathesis  the  writer  has  seen  a 
very  severe  reaction,  with  great  discomfort  for  ten  days,  pain,  great 
photophobia,  lacrymation,  severe  edema,  with  swelling  of  the  lid  so 
as  to  nearly  close  the  eye,  and  profuse  secretion. 

The  advantages  of  the  method  are  its  simplicity  and  ease  of  appli- 
cation, its  rapidity,  but  to  my  mind  especially  its  applicability  in  febrile 
cases  where  tuberculin  is  contraindicated,  and  in  children  who  are 
frightened  by  the  hypodermic  injection.  It  is  too  soon  as  yet  to  decide 
on  the  reliability,  utility,  and  safety  of  these  tests,  and  in  view  of  the 
large  number  of  latent,  unsuspected  cases  of  tuberculosis,  a  positive 
reaction  in  apparently  healthy  people  cannot  be  regarded  as  proving 
them  unreliable.  Only  time  and  clinical  work  can  decide  the  percentage 
of  reliability,  which  has  been  reported  anywhere  from  fifty  to  ninety- 
eight  per  cent,  the  statistics  of  different  authors  differing  widely.  Some, 
especially  French  writers,  are  enthusiastic;  some  well-known  authori- 
ties, like  Moeller  and  M.  Wolff,  have  given  them  up  entirely  as  no  more 
simple  and  far  less  reliable  than  the  older  method.    It  seems,  however. 


MODIFICATIONS  OF   THE  TUBERCULIN  TEST  349 

probable  that  the  cutaneous  method,  and  even  the  more  general!}'  applica- 
ble conjunctival  method,  cannot  be  regarded  as  complete  substitutes  for 
subcutaneous  injection,  but  only  as  an  occasional  resort  in  the  cases 
noted. 

It  would  seem  that  the  cutaneous  application  is  chiefly  useful  nega- 
tively and  in  nurslings  under  one  year,  and  may  possibly  prove  useful 
in  suggesting  the  presence  of  latent  foci,  while  the  conjunctival  is  more 
useful  clinically  and  in  the  diagnosis  of  active  trouble  (Wolff-Eisner, 
'08;  Engel  and  Bauer,  '07;  Warfield,  '08).  The  negative  result  of  a 
cutaneous  test  is  strong  evidence  of  the  absence  of  tuberculosis,  but  a 
positive  reaction,  save  in  infants,  as  noted,  cannot  safely  be  made  the 
basis  of  a  diagnosis  of  active  tuberculosis;  but  it  should  cause  us  to 
reexamine  the  case  most  closely  and  apply  the  subcutaneous  test.  At 
present  the  tendency  to  accept  a  positive  cutaneous  reaction  as  proof  of 
active  tuberculosis  in  adults  seems  likely  to  lead  to  errors  in  diagnosis. 
Detre  ('08)  has  suggested  the  use  of  the  cutaneous  test  to  distinguish 
between  human  and  bovine  infection,  using  human  and  bovine  filtrates 
cutaneously  in  parallel  rows.  Sixty-nine  per  cent  of  his  cases  reacted 
to  the  human  inoculation ;  only  four  per  cent  to  the  bovine ;  twent3'-two 
per  cent  to  both.     This,  however,  will  need  further  proof. 

The  specific  nature  of  anaphylactic  reactions  is  made  the  basis  of  a 
diagnostic  test  in  tuberculosis  by  Yamanouchi  ('08)  by  transferring  the 
fresh  blood  or  serum  of  the  patient  to  healthy  young  rabbits  (weight, 
400-800  gm.).  About  5  c.c.  of  blood  are  withdrawn  from  a  vein  into 
2  c.c.  of  one-per-cent  sterile  sodium-citrate  solution  to  prevent  coagula- 
tion. This  is  injected  without  delay  into  the  peritoneum  of  a  rabbit,  or 
the  same  amount  of  fresh  blister  serum  may  be  employed. 

After  twenty-four  hours  5  c.c.  of  a  saline  extract  of  tubercle  bacilli  are 
injected  intravenously.  Instead  of  this,  from  i  to  1  c.c.  of  old  tuberculin, 
diluted  to  5  c.c,  may  be  used.  If  no  symptoms  of  anaphylaxis  follow 
immediately,  the  same  dose  is  repeated  twenty-four  hours  later,  when  the 
sudden  death  with  respiratory  failure  and  convulsions  ensues  if  blood  from 
a  tuberculous  subject  has  been  used;  otherwise,  no  apparent  irconvenience 
results  even  after  further  repetition  of  the  toxin  injection. 

Yamanouchi  details  42  cases  of  tuberculosis  and  12  of  other  diseases, 
with  miiform  success  in  their  differentiation.  Baldwin,  of  Saranac,  has 
been  able  to  confirm  the  results  in  4  cases  thus  far. 

The  Agglutinative  Serum  Reaction. — A  few  years  ago  Arloing  and 
Courmont  ('05)  recommended  this  reaction  as  a  diagnostic  measure  in 
tuberculosis.  Homogeneous  culture  of  bacilli  are  obtained  by  a  special  cul- 
ture method  (growth  on  glycerin  peptone  bouillon  of  old  cultures  which 
are  shaken  up  to  insure  even  distribution  and  yield  a  homogeneous  mixture 
of  bacilli).  Mixtures  of  the  serum  of  the  suspected  case  with  this  culture 
or  with  a  dead  culture  which  can  also  be  used  (Koch  and  Remberg)  in 


350  DIAGNOSIS 

portions  of  1  to  5,  1  to  10,  and  1  to  20,  are  examined  at  twenty-four-hour 
intervals,  both  with  the  eye,  to  note  the  clearing  of  the  serum,  and  the 
deposit  of  small  flocculi,  if  positive,  or  with  the  microscope  to  note  the 
clumping  of  the  bacilli,  which  should  occur  with  tuberculous  sera  only. 

French  authors  have  been  very  optimistic  about  this  test,  but  the 
workers  of  other  countries  have  been  unable  to  verify  their  results.  Among 
others,  Kinghorn  and  Twitchell,  in  1900,  reported  a  careful  study  of  the 
subject,  through  two  years,  in  which  they  came  to  the  conclusion  that 
it  is  not  a  specific  sign  of  clinical  tuberculosis,  since  healthy  and  tuber- 
culous sera  have  practically  the  same  agglutinative  properties.  They, 
therefore,  conclude  that  it  is  of  no  value,  especially  for  early  cases,  and 
this  is  in  accord  with  the  more  recent  opinions  of  the  students  of  the 
subject. 

Cijtodia gnosis  (Widal). — This  depends  on  the  study  of  the  cellular 
elements  of  the  serum  in  tuberculous  subjects.  This  serum  is  either 
collected  from  blisters  or  from  natural  collections  in  the  pleura  or  else- 
where, and  is  mixed  with  nine-tenths  per  cent  salt  solution,  with  a  two- 
tenths  per  cent  ammonium  oxalate  addition  to  prevent  the  cells  from 
being  caught  in  the  fibrinous  deposit.  The  fluid  is  then  ceutrifuged 
and  the  cells  are  studied  microscopically  after  spreading  and  drying 
in  the  air,  and  staining  with  eosin-methylenc  blue.  Widal  believes  that 
the  preponderance  of  lymphocytes  speaks  for  tuberculosis,  while  a  major- 
ity of  polynuclears  of  the  neutrophile  and  eosinophile  varieties  excludes 
it.     Outside  of  France  this  method  has  not  won  general  acceptance. 

Opsonic  Index. — The  attempt  to  apply  Wright's  work  on  opsonins 
and  the  opsonic  index  to  the  diagnosis  of  tuberculosis  has  so  far  not 
been  as  successful  as  has  been  its  use  in  therapeutics,  and  the  results 
obtainable  scarcely  justify  the  amount  of  time  and  labor  necessary  for 
its  very  elaborate  technic.  This  technic  (see  Appendix)  is  only  appli- 
cable by  an  expert  in  the  best-equipped  laboratories,  and  with  ample 
assistance,  and  the  claims  of  its  advocates  as  to  its  diagnostic  value  have 
not  been  corroborated  by  the  careful  work  of  such  observers  as  Simon, 
Cole,  Potter,  Thomas,  and  others.  It  is  needless,  therefore,  to  enter 
very  fully  into  the  subject  in  this  place,  but  the  principles  on  which  it 
rests  demand  some  notice,  and  the  claims  of  its  advocates  should  be 
stated. 

Opsonins  are  those  substances  in  the  blood  which  so  act  on  the  bac- 
teria as  to  facilitate  their  phagocytosis.  They  are  normally  present 
in  the  blood  (normal  opsonins)  and  are  present  in  disease  (immune 
opsonins)  and  are  supposed  to  represent  one  of  the  efforts  of  nature 
against  the  infection.  The  opsonic  index  is  the  ratio  of  phagocytosis  in 
the  serum  of  the  blood  of  the  patient  to  that  in  the  serum  of  normal 
blood  taken  from  one  or  more  healthy  people.     Thus  if  a  hundred  leu- 


MODIFICATIONS  OF   THE  TUBERCULIN  TEST  351 

oocytes  in  serum  from  a  tuberculous  case  take  up  50  bacteria  and  a 
similar  number  in  serum  from  a  control  take  up  lUO,  the  index  is  ^%, 
or  0.5.  The  normal  index  is  from  0.8  to  1.3,  and  according  to  Birkett 
and  Bulloch  ("05)  is  fairly  fixed,  though  Thomas  ("07)  disputes  this. 

Diagnostic  conclusions  are  drawn  from  the  amount  of  phagocytosis 
as  to  the  presence  or  absence  of  tuberculosis.  Unfortunately,  it  is  chiefly 
in  advanced  cases  in  which  a  diagnosis  is  easy,  that  positive  conclusions 
are  justified,  as  even  its  advocates  admit   (Ross.  Birkett). 

In  tuberculosis  we  can  have  five  types  of  indices — normal,  high,  low, 
fluctuating,  and  a  heated  serum  index,  and  in  their  study  we  must 
consider  also  the  effects  of  rest,  exercise,  massage,  the  existence  of  other 
diseases  and  the  injection  of  tul)erculin,  and  also  must  compare  the  index 
of  the  blood  serum  with  that  of  the  serum  procured  from  other  fluids 
arising  near  the  focus  of  trouble. 

(a)  Normal  Index. — Wright  and  Eeid,  according  to  Potter,  claim 
that  with  a  persistently  normal  index  tuberculosis  can  be  excluded  with 
all  probability. 

(&)  High  Index. — Eoss,  of  Toronto,  considers  a  high  index  (1.4  or 
over)  on  several  occasions  diagnostic,  and  Birkett  thinks  it  is  a  valu- 
able sign  tliat  nature  is  combating  the  bacillus,  and  tlius  tliat  it  is  evi- 
^dence  of  active  tuberculosis  in  the  system.  Butler  Harris  says :  "  A 
valuable  feature  of  the  opsonic  inethod  lies  in  the  fact  that  a  new  weapon 
is  provided  for  accurate  diagnosis.  "Wriglit,  Bulloch,  Lawson,  Urwick, 
and  others  have  conclusively  sliown  that  no  normal  person  ever  gives  a 
high  index."  Bulloch,  who  is  much  more  conservative  in  his  claims, 
says:  "An  abnormally  high  index  is  probably  a  sign  of  infection,  but 
it  cannot  be  used  prognostically,  as  it  may  occur  in  cases  which  do  well 
and  in  those  which  are  quite  hopeless."  Wright  and  Reid,  quoted 
by  Potter,  consider  a  high  index  proof  of  a  systemic  tuberculous 
infection. 

(c)  Low  Index. — Harris  considers  that  this  occurs  in  all  early  cases 
of  tuberculous  infection  of  the  hings,  and  tliat  such  an  index  is  found 
in  cases  in  which  the  lesion  is  shut  off  almost  entirely  from  the  blood 
stream  and  little  or  no  bacteria  get  into  tlie  circulation.  Bulloch  says 
that  from  determinations  he  has  made  "  it  appears  that  an  index  below 
0.8  is  abnormal,  but  whether  it  actually  represents  that  an  infection  has 
already  taken  place  or  merely  may  take  place  it  is  impossible  to  say,  as 
the  diagnosis  at  very  early  stages  of  tuberculosis,  especially  of  the  lungs, 
is  an  impossibility  without  resort  to  the  tuberculin  test.  The  question 
whether  a  low  index  is  the  cause  or  the  effect  of  the  infection  is  unan- 
swerable at  the  present  time."  Eoss  doubts  its  reliability,  but  consid- 
ers an  index  of  0.6  or  lower  strongly  suggestive  of  tuberculosis,  but 
not  absolute.     Birkett  thinks  a  low  index  has  com])aratively  little  value, 


352  DIAGNOSIS 

as  several  types  of  infection  give   it,  such  as  pneumonia,  chorea,  and 
malignancy. 

Fluctuating  Index. — Birkett  considers  this  suggestive  of  tuberculosis 
if  the  patient  be  at  rest  in  bed,  but  only  severe,  easily  diagnosed  cases 
will  run  such  an  index  while  in  bed;  hence  he  considers  that  only  when 
normal  in  bed  and  becoming  fluctuating  by  exercise  or  massage  can  it 
be  valuable,  and  he  thinks  tbis  can  occur  in  quite  early  cases.  Ross 
considers  a  persistently  fluctuating  index  very  probable  evidence  of 
tuberculosis.  Harris  notes  that  in  doubtful  cases  where  there  is  no  tem- 
perature, if  frequent  readings  show  a  constantly  fluctuating  index,  a 
little  above  or  below  normal  alternately,  the  patient  is  probably  suffering 
from  an  early  tuberculous  infection. 

The  Heated  Serum  Reaction. — Heating  nornuil  serum  to  60°  C 
deprives  it  of  almost  all  its  ojjsonic  power,  but  with  tuberculous  serum, 
on  tbe  contrary,  there  is  a  marked  gain  in  opsonic  power  in  comparison 
to  tbe  normal.  In  this  connection  Birkett  says :  "  If  a  patient,  there- 
fore, wbo  is  obviously  reacting  from  some  toxin,  as  shown  by  constitu- 
tional symptoms,  fails  to  give  an  opsonic  index  with  heated  serum  of 
2.5  or  more,  I  believe  it  to  be  very  strong  evidence  against  tuberculosis 
being  tbe  cause  of  the  mischief.  .  .  .  But  this  does  not  apply  so  forcibly 
to  cases  running  an  apyrexial  course."  The  cases  where  a  heated-serum 
reaction  is  present  have,  according  to  Ross,  a  manifestly  toxic  nature 
(pyrexia),  in  which  a  diagnosis  is  usually  easy;  hence,  save  to  exclude 
typhoid,  it  has  not  much  practical  value,  though  in  such  cases  he  thinks 
it  as  diagnostic  as  a  Widal  test. 

Serum  from  a  focus  of  infection,  pus,  pleuritic,  or  peritoneal  exudate, 
joint  effusion,  etc.,  shows  a  much  lower  index  than  that  of  the  serum 
from  the  same  patient's  blood,  and  Birkett  considers  such  a  difference 
strongly  diagnostic,  while  similarity  of  the  indices  of  tliese  two  sera,  he 
thinks,  suffices  to  exclude  tuberculosis  in  the  process  yielding  the  effu- 
sion. However,  he  says  of  this  method :  "  Theoreticall}',  the  method  is 
ideal,  but  practically  it  is  disappointing,"  and  adds:  "Therefore  I  place 
very  little  reliance  on  this  method  as  a  help  to  diagnosis,"  although  he 
holds  that  a  nonfluctuating  index,  or  a  similar  index  for  blood  serum 
and  pus  serum,  is  very  strong  evidence  against  tuberculosis.  Da  Costa 
('07)  says  that  the  opsonic  index  can  be  helpful  in  determining  cases 
of  tuberculosis  by  the  fact  that  a  drop  in  the  opsonic  index  caused  by 
an  injection  of  tuberculin  is  greater  and  more  persistent  (a  week  or  so) 
in  tuberculosis  than  in  normal  people  (two  days).  As  to  the  diagnostic 
value  of  readings  of  the  opsonic  index,  Ross  considers  that  opsonic 
investigations  of  the  blood  for  diagnostic  purposes,  while  valuable  for 
exceptional  cases,  is  not  of  use  in  ordinary  incipient  cases,  and  considers 
that  the  two  most  important  factors  are   abnormal  phagocytosis  with 


DIFFERENTIAL   DIAGNOSIS  353 

heated  serum  and  fluctuation  of  the  index,  whether  spontaneous  or  as 
a  result  of  exercise,  massage,  or  tuherculin  injections.  Bulloch  ('05) 
says :  "  Much  more  evidence  must  he  accumulated  hef  ore  a  definite  opin- 
ion can  he  expressed  upon  this  important  point." 

After  such  a  resume  of  the  views  of  those  most  familiar  with  opsonic 
technic,  it  seems  to  me  justifialde  to  conclude  that  as  yet  we  have  not 
reached  a  ])oint  in  the  development  of  this  method  where  the  informa- 
tion it  can  give  us  diagnostically  is  certain  enough  to  demand  a  resort 
to  so  complicated  a  technic  in  our  diagnostic  work. 

DIFFERENTIAL   DIAGNOSIS 

There  are  various  conditions,  hoth  pulmonary  and  systemic,  which 
can  closely  simulate  pulmonary  tuherculosis  or  he  simulated  hy  it,  and 
can  render  the  diagnosis,  even  of  an  advanced  case,  diificult. 

Of  these  the  one  that  will  most  frequently  be  met  with  is  bronchopneu- 
monia, and  as  pulmonary  tuberculosis  so  commonly  manifests  itself  as  a 
broncliopneumonia,  the  determination  of  the  real  etiology  of  the  trouble 
may  be  difficult.  This  is  especially  the  case  when  we  are  dealing 
with  the  influenza  pneumonias  which  are  so  common.  Finkler  and 
"Wassermann  have  also  drawn  attention  to  the  occurrence  of  strepto- 
coccal bronchopneumonias  that  can  be  confusing. 

In  every  influenza  epidemic  one  sees  some  cases  which  develop  into 
tuberculosis  and  some  which  simulate  it  closely,  but  finally  clear  up, 
leaving  an  apparently  intact  lung,  justifying  the  belief  that  the  sus- 
picious signs  were  due  to  the  influenza,  although,  of  course,  it  cannot 
be  denied  that  it  may  have  been  an  alwrtive  tuberculosis. 

While  such  cases  are  usually  in  children,  and  while  West  and  Brown 
have  both  stated  that  a  bronchopneumonia  in  an  adult  is  presumptively 
tuberculous,  the  author  has  seen  cases  in  adults  whose  signs  were  those 
of  tuberculosis  and  which  later  cleared  up  entirely.  Lord,  of  Boston, 
has  reported  a  number  of  carefully  observed  cases  of  chronic  influenza 
simulating  tuberculosis,  and  it  behooves  us  to  keep  this  possibility  always 
in  mind. 

In  children,  after  attacks  of  grip,  it  is  often  most  diificult  to  decide 
whether  an  apical  catarrh  is  tuberculous  or  influenzal,  the  physical  signs 
being  identical.  The  presence  of  the  influenza  Ijacillus  is  not  enough 
to  exclude  tuberculosis,  and  in  young  children  it  is  usually  difficult  to 
get  any  sputum  for  examination.  Lindsay  considers  that  the  signs  of 
bronchopneumonia  are  usually  bilateral,  but  the  author  has  seen  cases 
in  which  they  were  unilateral  and  whose  subsequent  course  sufficed  to 
exclude  tuberculosis.  The  history  in  influenza  is  usually  shorter  and 
the  symptoms  at  first  more  acute,  but,  as  noted,  the  physical  signs  are 
24 


354  DIAGNOSIS 

identical  and  the  temperature  curve  cannot  be  relied  on,  and  in  grip 
we  can  have  sweats,  hectic  and  wasting   (Fraenkel,  Lindsay). 

Personally  1  believe  tliat  the  course  of  the  trouble,  which  is  relatively 
short  in  grip  and  tends  to  clear  up,  while  it  is  protracted  and  obstinate 
in  tuberculosis  and  tends  to  spread,  must  be  our  chief  reliance,  but,  as 
noted  above.  Lord  has  seen  cases  with  a  prolonged  course. 

Lobar  Pneumonia. — This  may  at  times  be  tuberculous,  but  in  this 
case  the  imperfect  resolution,  the  persistence  of  tem])erature,  the  pro- 
gressi\;e  weakening,  and  the  appearance  of  bacilli,  which  in  acute  tuber- 
culous pneumonia  is  not  long  delayed,  quickly  clear  the  diagnosis. 

However,  I  have  found  that  in  negroes,  who  so  often  develop  a 
tuberculous  pneumonia  with  rapid  breaking  down  of  the  lung  and  fatal 
course  (acute  ulcerous  phthisis),  not  a  few  cases  of  ordinary  pneumonia 
will  raise  our  anxiety  by  their  atypical  course,  absence  of  distinct  crisis 
and  very  slow  resolution,  and  will  3^et  finally  clear  up  satisfactorily  and 
permanentl}',  and  I  have  come  to  expect  a  slow  atypical  course  in  this 
race. 

Chronic  pneumonia  (cirrliosis  imlmonum)  can  very  closely  simulate 
fibroid  phthisis,  and  here  the  histor}^  and  the  persistent  absence  of  bacilli 
will  often  be  our  only  guide,  though  in  fibroid  phthisis  bacilli  can  be 
absent  for  long  periods.  In  such  cases  only  an  autopsy  will  at  times 
serve  to  clear  up  the  doubt. 

Acute  hronchitis  should  rareh^  give  rise  to  difficulty,  but  in  old  peo- 
ple, where  it  tends  to  a  sluggish  course,  the  distinction  may  not  be  easy. 
The  facts  on  which  we  have  to  depend  are  the  al:)sence  of  dullness,  the 
absence  of  marked  alterations  of  the  respiratory  murmur,  the  fact  that 
bronchitis  is  commonest  in  the  lower  parts  of  the  lung,  and  if  general 
clears  up  above  sooner  than  l^elow;  the  ])uljbling  or  sibilant  rather  than 
crepitant  nature  of  the  rales,  the  fact  that  in  bronchitis  the  rales  are 
usually  similar  on  both  sides,  which  is  rare  in  tuberculosis,  and  that 
they  are  disseminated  rather  than  localized,  and,  finally,  tlie  fact  that  in 
tuberculosis  a  sputum  so  abundant  will  usually  show  bacilli.  The  tem- 
perature also  in  bronchitis  is  usually  only  temporar3^  However,  it  must 
be  recalled  that  tuberculosis  at  times  can  begin  as  a  generalized  bronchitis. 

Chronic  bronchitis  is  difl'erentiated  in  the  same  way,  the  history  and 
the  sputum  examination  being  especially  useful. 

Asthma  gives  rise  to  diagnostic  difficulties  chiefly  in  masking  a  tuber- 
culous focus,  and  in  doubtful  cases  it  is  necessary  to  wait  for  a  time  when 
the  asthmatic  signs  are  absent  before  we  can  satisfactorily  search  for 
the  coexisting  tuberculous  trouble. 

The  two  conditions  have  been  supposed  to  be  antagonistic,  but  not 
a  few  real  asthmatics  will  be  found  among  our  tuberculous  cases,  not  to 
mention  the  pseudo-asthma  we  find  in  old  fibroid  cases. 


DIFFERENTIAL   DIAGNOSIS  355 

Tlie  X-ray  is  very  useful  in  demonstrating  a  concealed  focus  in  an 
asthmatic,  and  the  sj)utum  examination  is  very  important  in  all  doubt- 
ful cases,  hut  the  presence  of  tlie  spirals  of  C*urschniann  or  of  Charcot- 
Leyden  crystals  in  a  sputum  does  not,  of  course,  exclude  the  existence 
of  tuberculosis. 

Pleurisy. — The  fact  that  the  large  majority  of  pleurisies  have  a 
tuberculous  basis  is  now  so  well  recognized  that  we  are  less  likely  than 
formerly  to  overlook  a  tuberculosis  masquerading  as  a  pleuris}^  with 
effusion. 

In  every  pleurisy  we  should  study  the  apices  as  carefully  as  the  heart 
in  rheumatism,  but  should  not  forget  that  pleurisy  can  produce  transient 
rales  at  the  apex  that  cannot  be  differentiated  from  fine  crejntant  rales. 
While  the  fluid  in  a  pleurisy  rarely  shows  bacilli  microscopically,  even 
when  we  precipitate  with  alcohol,  it  should  always  be  examined,  and 
animal  experiments  resorted  to  to  determine  the  possible  presence  of 
the  germ. 

The  appearance  of  the  fluid  is  of  some  value,  as  tuberculous  fluid 
is  frequently  bloody  and  rarely  purulent,  but  if  the  possibility  of  cancer 
exists,  in  which  bloody  fluid  is  also  common,  this  will  not  help  us. 

The  fluoroscope  I  have  found  of  help  as  revealing  sometimes  apical 
shadows  and  more  commonly  enlarged  broncliial  glands. 

Bronchiectasis  must  at  times  be  differentiated  from  old  cases  of 
tuberculosis  with  cavitation.  Here  we  rely  cliiefly  on  tlie  history  of  a 
persistent  bronchitis  without  marked  constitutional  symptoms  and  with 
the  discharge  of  large  amounts  of  fetid,  stinking  sputum  at  intervals, 
with  intervening  periods  when  but  little  is  brought  up. 

In  some  cases  of  tuberculosis  the  F])utum  can  at  times  be  offensive, 
but  never  has  the  persistentl}'  foul  odor  of  bronchiectasis. 

A  pronounced  case,  with  its  remarkably  abundant  paroxysmal  empty- 
ings of  the  tul)es  and  a  sjmtum  which  separates  into  three  layers,  is  too 
typical  to  cause  any  doubt,  while  so  abundant  a  sputum  in  tuberculosis 
would  alwa3's  show  bacilli  which  here  are  absent,  as  are  also  elastic 
fibers. 

The  presence  of  blood  cannot  help  us,  as,  while  rare,  it  can  occur  in 
bronchiectasis.  Fever  is  often  absent,  and  when  present  is  irregular 
and  intermittent,  ])eing  usually  absent  just  after  the  evacuation  of  the 
tubes.  Bronchiectasis  usually  affects  the  lower  bronchi  and  the  upper 
lung  is  apt  to  be  free,  while  in  tuberculosis,  if  a  cavity  exists  in  the 
lower  lobes,  there  will  practically  always  be  considerable  old  trouble  in 
the  upper  part.  Tuberculosis,  when  cavities  are  present,  is  also  always 
bilateral,  while  bronchiectasis  is  usually  unilateral. 

Bronchiectatic  cavities  show  up  as  spindle-shaped,  irregular  shadows, 
usually  radiating  down  and  out,  and  it  is  typical  of  them  that  after 


356  DIAGNOSIS 

evacuation  of  their  contents  they  nearly  or  totally  disappear  from  the 
screen.  If,  however,  as  Holzknecht  notes,  there  is  much  peribronchial 
thickening,  considerable  shading  may  be  left,  and  we  may  be  in  doubt 
whether  we  are  dealing  with  a  cavity  in  the  lung  which  has  emptied  or 
a  bronchiectasis.  Around  tuberculous  bronchiectasis  there  will,  of  course, 
be  infiltration. 

Pneumothorax  can  be  mistaken  for  a  large,  smooth-walled  cavity,  as 
the  latter  can  yield  amphoric  breathing,  tympanitic  resonance,  and 
large  resonant  rales,  but  careful  physical  examination  should  settle  the 
doubt,  while  the  X-ray  gives  great  assistance  in  diagnosis.  The  sudden 
dyspnea  has  been  taken  for  asthma,  but  the  cardiac  dislocation,  the 
bulging  chest,  and  the  percussion  and  auscultation  findings  should  clear 
up  the  question. 

Actinomycosis. — This  disease  can  present  insuperal)le  difficulties  in 
earl}^  primary  cases,  but,  fortunately,  primary  actinomycosis  of  the  lung 
is  rare  (twelve  to  fifteen  per  cent  of  all  cases,  Fraenkel),  and  if  sec- 
ondary, the  primary  lesion  in  the  tongue,  jaw,  intestines,  or  liver  makes 
the  diagnosis  simple,  though  it  must  be  recollected  that  the  two  condi- 
tions at  times  coexist. 

In  early  cases  a  moderate  cough,  with  scant  expectoration  and  signs 
of  pulmonary  catarrh,  give  no  points  on  which  to  base  a  diagnosis, 
though  the  central  or  basal  location  common  in  this  disease  may  l)e  sug- 
gestive. Even  after  the  first  stage  the  usually  very  chronic  course — 
the  wasting  fever  and  formation  of  cavities,  and  the  subsequent  fibrosis 
with  shrinkage,  and  the  tendency  to  adhesive  or  effusive  pleurisy — can 
be  strongly  suggestive  of  tuberculosis. 

Of  course  tlie  discovery  of  the  typical  organism  in  the  sputum  is 
final,  but  this  may  not  appear  till  late,  and  the  absence  of  bacilli  and 
elastic  fibers  cannot  exclude  tuberculosis,  save  in  cases  with  advanced 
lesions,  where  they  will  scarcely  be  absent. 

On  the  whole,  the  history  of  an  occupation  wliich  brings  one  much 
in  contact  with  grain  or  hay  (coachmen,  millers,  etc.),  the  usually  lat- 
eral basal  location  of  the  trouble,  the  tendency  to  bulging  of  the  side, 
the  formation  of  thoracic-wall  abscesses  and  fistula^,  and  the  pain  in  the 
side  must  be  our  chief  reliance. 

The  good  effect  of  potassium  iodid  in  many  cases  cannot  be  relied 
on  in  diagnosis,  as  it  is  often  without  therapeutic  effect. 

Echinococnts  cyst  of  the  lung  is  not  only  an  exceedingly  rare  con- 
dition, but,  practically  always,  only  diagnosticable  l)y  the  microscope. 

^AHien  the  cyst  evacuates  itself,  shreds  of  membrane,  booklets,  or 
daughter  cysts  may  be  found,  and  as  this  evacuation  is  often  accom- 
panied with  hemorrhage,  these  should  be  looked  for  in  examinations  of 
hemoptysis.  • 


DIFFERENTIAL   DIAGNOSIS  357 

The  physical  signs  are  of  little  assistance.  The  disease  is  commonest 
in  the  bases  and  rare  in  the  apices;  moreover,  there  may  be  localized 
bulging  of  the  chest  wall,  and  if  the  cyst  be  full  there  will  be  dullness 
and  weak  breath  sounds,  but  no  rales. 

Fever  is  absent.  Even  if  a  cyst  be  suspected,  puncture  for  diagnostic 
purposes  is  not  wise,  as  such  puncture  has  frequently  proven  fatal  with 
severe  pseudo-asthmatic  attacks  and  edema  of  the  lung  (Ma3'dl).  It  is 
probable  that  the  X-ray  will  prove  our  most  reliable  means  of  diagnosis, 
judging  from  the  cases  of  Eosenfeld  and  of  Levy  Dorn-Zadek.  The 
skiagraph  of  the  latter  showed  in  the  right  lung  a  more  or  less  circular 
clear  space  surrounded  with  a  dark  border,  which  below  was  prolonged 
by  a  dark  l)and  into  the  dome  of  the  diaphragm,  while  on  the  left  was 
a  smaller  area  not  so  connected.  If  the  cyst  were  full  the  shadow  would, 
of  course,  be  solid. 

Fungous  Infection  of  the  Lung. — Certain  fungi,  nota1)ly  the  Asper- 
gillus fumigaius,  the  stroptothrix,  and  the  cladothrix,  as  well  as  certain 
protozoa,  can  grow  and  produce  pathological  changes  in  the  lung  with 
S3anptoms  suggesting  the  presence  of  tuberculosis.  The  diagnosis  can 
only  be  made  by  discovering  these  various  organisms  in  the  sputum. 

In  doubtful  cases,  Avhere  tubercle  bacilli  cannot  be  demonstrated,  we 
should  therefore  be  careful  not  only  to  stain  for  tubercle  bacilli  but  to 
look  for  other  organisms  with  special  stains  (carbol  thionin-aqueous 
salfranin). 

Pulnionarg  Si/pliilis. — While  syphilis  can  be  localized  in  the  lung, 
the  physician  should  be  very  careful  before  he  makes  such  a  diagnosis, 
and  the  coexistence  of  syphilis  and  tuberculosis  is  too  common  to  justify 
us  in  concluding  that  a  pulmonary  lesion  in  a  syphilitic  patient  is 
syphilitic  until  we  have  used  every  means  of  excluding  the  one  and 
diagnosticating  the  other.  While,  however,  pulmonary  syphilis  is  rare, 
it  occurs  in  a  certain  number  of  syphilitics,  Haslund,  quoted  by  West, 
rejiorting  2  diagnoses  intra  ritain  in  6,000  syphilitics;  and  in  18  syph- 
ilitics dying  of  the  disease,  3  showed  pulmonary  syphilis.  Excluding 
the  white  pneumonia  of  the  new-born,  which  here  does  not  interest  us, 
there  are,  according  to  the  excellent  classification  of  Sokolowski,  three 
forms  of  pulmonai-y  syphilis — a  focal,  a  destructive  gummatous,  and  a 
fibroid — though  French  authors  make  numerous  classes. 

The  last  of  these  forms  is  the  more  usual,  but  the  first  is  the  most 
important,  as  it  can  simulate  early  tuberculosis,  and  its  recognition  lias 
valuable  therapeutic  results,  while  the  latter  is  scarcely  to  be  distin- 
guished from  advanced  fil)roid  phthisis,  and  is  therapeutically  uninflu- 
enced by  the  iodids.  The  focal  form  can  deceive  us  entirely.  There  is 
an  area  of  consolidation  and  catarrli  most  commonly  around  the  root 
of  the  lung,  Init  at  times  at  the  apex.     The  cough  can  be  moderate. 


358  DIAGNOSIS 

but  at  times  it  is  very  obstinate  and  liarassing,  and  while  fever  can  be 
present,  it  is  usually  absent.  I  had  such  a  case  under  my  care  where 
the  signs  were  typically  those  of  apical  tuberculosis,  and  it  had  been  so 
diagnosed  by  an  excellent  observer,  but  its  failure  to  respond  to  treat- 
ment and  the  development  of  certain  throat  lesions  aroused  my  sus- 
picions, and  reexamining  the  history  carefully  in  the  absence  of  the 
patient's  wife  I  got  a  frank  confession  of  a  syphilis  of  two  years'  dura- 
tion, and  the  rapidity  with  which  all  signs  and  symptoms  cleared  up 
on  iodid  of  potash,  and  the  subsequent  perfect  health  for  two  years, 
justified  the  diagnosis. 

In  another  case  there  was  consolidation  between  the  spine  and  the 
angle  of  the  scapula  beautifully  shown  by  the  fluoroscope,  Avith  constant 
harassing  cough,  but  with  very  little  expectoration  and  no  fever. 

This  patient  had  received  a  test  dose  of  tuberculin  from  other  hands, 
and  was  said  to  have  reacted  positively. 

Here  also  iodid  removed  all  symptoms  rapidly,  and  for  the  six 
months  during  which  I  was  able  to  follow  the  case  there  was  no  return, 
probably  justifying  the  diagnosis  of  sy2:)hilis. 

The  obstinate  cough  has  been  supposed  to  be  a  diagnostic  sign  of 
pulmonary  syphilis,  but  as  it  is  not  different  from  the  cough  produced 
by  enlarged  bronchial  glands,  and  as  these  exist  often  in  syphilis,  its 
diagnostic  value  is  doubtful.  The  therapeutic  diagnosis  by  the  use  of 
iodid  of  potash  is  very  relialile.  Xot  only  the  symptoms,  but,  to  be  cer- 
tain, all  signs  must  disappear,  as  otherwise  one  may  have  removed  the 
syphilitic  element  but  left  l)ohind  a  coexisting  tuberculous  lesion. 

The  destructive  form  the  M^riter  has  not  seen,  and  it  is  said  to  be , 
very  rare,  but  can  go  on  to  cavity  formation.  The  sclerotic  form  is 
marked  especially  by  dyspnea,  or  even  pseudo-asthma,  but  this  cannot 
be  considered  characteristic,  as  the  same  can  occur  in  fibroid  phthisis, 
from  which  it  is  impossible  to  differentiate  it.  Aside  from  the  dyspnea 
there  are  physical  signs  of  fibrosis  with  bronchostenosis,  and,  as  would 
be  expected  from  the  nature  of  the  lesions,  iodids  have  no  effect. 

To  recapitulate  the  points  on  which  one  can  base  a  diagnosis  of  pul- 
monary syphilis,  they  are  the  existence  of  syphilitic  infection,  laryngeal 
or  pharyngeal  lesions,  less  constitutional  symptoms  than  we  would  expect 
in  tuberculosis,  moderate  or  no  fever,  and,  chiefly,  the  therapeutic  test 
of  mixed  treatment,  with  subsequent  observation  of  the  case.  On  account 
of  the  harmful  effect  of  iodid  of  potash  on  tuberculosis  one  should  not 
resort  to  it  unless  suspicions  are  very  strong. 

Malignant  disease  of  the  hings,  whether  carcinoma  or  the  much  rarer 
sarcoma,  is  fortunately  uncommon,  few  clinicians  having  seen  many 
cases. 

When  located  in  the  apices  or  running  a  slow  course  it  may  be  very 


DIFFERENTIAL   DIAGNOSIS  359 

difficult  of  diagnosis,  but  as  the  large  majority  are  secondary  to  malig- 
nant growths  elsewhere  the  diagnosis  is  usually  facilitated. 

In  view  of  its  occurrence  secondarily  a  very  careful  history  and  a 
thorough  examination  of  the  body  for  cancerous  growth  is  necessary. 

Aside  from  this  the  points  deinanding  attention  are  as  follows.  They 
are  apt  to  be  central  or  basal  in  location,  present  a  more  marked  and 
more  rapidly  developing  exhaustion  than  tuberculosis,  while  the  wast- 
ing, on  the  contrary,  is  less  pronounced  than  the  signs  would  seem  to 
justify.  The  waxy  pallor  of  the  cancerous  cachexia  is  suggestive  if 
present,  but  may  be  absent  till  later;  the  infiltration  develops  very  rap- 
idly, sucli  a  rapidity  in  tuberculosis  being  accompanied  by  severe  con- 
stitutional symptoms,  and  the  dyspnea  comes  on  early  and  is  more 
marked  than  in  filjroid  plithisis. 

Pain  in  the  chest  is  more  common  and  far  more  severe,  while  fever 
is  usually  absent.  The  cough  is  very  variable,  some  authors  reporting 
it  hard  and  obstinate,  some  moderate,  due  probably,  as  in  syphilis,  to 
the  greater  or  less  involvement  of  the  bronchial  glands. 

The  expectoration  is  scanty  and  the  currant-jelly  expectoration,  held 
by  some  to  be  typical,  can  be  entirely  absent,  though  there  is  a  marked 
tendency  to  bloody  expectoration. 

Symptoms  of  pressure  on  the  veins  or  lymphatics  are  common,  so 
that  we  can  have  dilated  bunches  of  small  veins  in  the  thorax,  and  in 
late  cases  enlarged  glands,  especially  above  tlie  clavicle  and  in  the  axilla, 
can  be  found.  Pleuritic  effusions  are  common,  but  share  with  tubercu- 
lous effusions  a  tendency  to  bloodiness.  Tlie  physical  signs  are  not 
very  characteristic,  though  Fraenkel  thinks  that  the  lack  of  corre- 
spondence between  the  flatness  on  percussion  (with  greatly  increased 
resistance)  and  the  insignificant  breath  changes— i.  e.,  weakened  breath- 
ing and  few  or  no  rales — is  a  sign  of  great  value. 

If  cancer  cells  are  found  in  the  sputum  they  are,  of  course,  decisive, 
but  this  does  not  often  occur.  However,  as  has  been  said  in  connection 
with  echinococcus  disease  and  fungous  disease,  in  doubtful  cases  the 
sputum  examination  must  be  thorough,  histologic  as  well  as  bacteriologic. 

Heart  lesions  wliieh  cause  congestion  of  the  lung  and  hemoptysis, 
chiefly  mitral  stenosis,  are  at  times  diagnosed  as  tuberculosis,  but  a 
careful  and  systematic  study  of  our  cases  should  make  this  mistake 
impossible. 

Malaria  is  a  very  common,  ])robal)ly  the  most  common,  source  of 
error  in  diagnoses  which  exclude  tuberculosis  erroneously. 

Every  year  one  sees  many  cases  which  have  been  treated  for  longer 
or  shorter  periods  for  malaria  when  the  disease  was  a  more  or  less 
incipient  tuberculosis,  and  while  in  a  malarial  country  where  so  many 
cases  of  irregular  fever  are  seen,  and  where  so  many  are  really  atypical 


360  DIAGNOSIS 

malaria,  this  is  perhaps  natural,  it  is,  now  that  the  microscope  is  avail- 
able to  all  and  can  so  easily  settle  the  question,  no  longer  excusable. 

Blood  examinations  must,  it  need  hardly  be  said,  be  thorough  and 
frequent,  and  the  recognition  of  the  plasmodium  certain  and  positive 
before  we  can  afford  to  treat  a  slow,  irregular,  remitting  fever  as  malaria 
and  exclude  tuberculosis  entirely. 

The  therapeutic  test  of  quinin,  while  valuable,  must  be  made  with 
caution,  as  it  will  often  suppress  a  tuberculous  fever  for  a  time. 

Moreover,  it  should  be  standard  practice  in  every  case  of  such  sus- 
picious fever  to  examine  the  sputum  and  the  lungs  most  carefully  and 
repeatedly,  and  if  necessary  one  should  resort  to  tuberculin. 

Typhoid  fever  is  frequently  given  in  a  history  as  the  beginning  of 
a  tuberculosis,  but  it  is  probable  that  some  of  these  cases  were  merely 
the  acute  beginning  of  a  case  that  later  took  on  a  more  chronic 
course. 

The  diagnosis  of  acute  miliary  tuberculosis  from  typhoid  fever  is  one 
of  the  most  difficult  in  medicine,  and  often  can  only  be  made  at  the 
autopsy,  hence  in  every  case  of  suspected  typhoid  of  slightly  atypical 
course  we  should  take  care  to  exclude  this  possibility.  The  Widal  reac- 
tion is  here  of  great  value  if  past  typhoid  can  be  excluded.  Ausculta- 
tion is  not  of  great  assistance  owing  to  the  frequency  of  pulmonary  signs 
in  typhoid. 

The  temperature  in  acute  miliary  tuberculosis  is  much  more  irreg- 
ular as  a  rule  and  may  intermit  entirely,  and  tends  to  marked  remis- 
sions, the  respiration  is  hurried,  the  face  anxious,  and  there  is  an  omi- 
nous cyanosis.  Osier  states  that  "  leucocytosis  is  more  common  in  miliary 
tuberculosis  than  in  typhoid,  in  which  leucopenia  is  the  rule."  The 
typhoid  bacillus  can  be  cultivated  from  tlic  stools  or  the  blood. 

Persistent  anemia,  or  especially  chlorosis  or  neurasthenia  or  dys- 
pepsia, are  so  often  tlie  initial  symptoms  of  tuberculosis,  and  so  many 
incipient  cases  are  treated  for  these  diseases,  that  the  possibility  of  tuber- 
culosis should  be  kept  in  mind.  Chlorosis  is  so  often  accompanied  by 
slight  fever  and  so  often  precedes  tuberculosis  that  the  view  of  some  that 
it  is  really  a  tuberculous  condition  seems  reasonable,  and  the  use  of  tuber- 
culin justified. 

In  neurasthenia  and  dyspepsia  the  thermometer  is  valuable,  and  the 
all  too  common  custom  of  explaining  away  a  cough  that  cannot  be 
stopped  as  a  "  stomach  cough,"  and  of  treating  it  with  anodyne  cough 
mLxtures,  cannot  be  too  strongly  reprobated. 

If  a  cough  exists  it  has  some  physical  cause,  which  in  the  large 
majority  of  cases  can  be  discovered  and  removed,  and  no  physician  is 
doing  his  duty  to  his  patient  who  fails  to  make  a  thorough  physical 
examination  into  its  cause. 


ON  THE  RECOGNITION   OF   STAGES  361 

ON   THE   RECOGNITION   OF   STAGES 

If  the  results  of  the  study  of  tlie  SA'mptoms  and  signs  of  our  cases 
are  to  be  utilized  in  widening  our  knowledge  of  this  disease,  if  the 
observations  of  many  separated  observers  are  to  be  correlated  into  a 
complete  whole,  it  is  essential  that  we  have  a  system  of  classification 
for  our  cases  by  stages  which  shall  be  used  by  all  physicians  in  their 
work.  Many  such  S3'stems  have  been  suggested  (Petruschky,  Brehmer, 
Koniger,  etc.),  but  that  put  forward  by  Turban  in  the  A'ear  1899  has 
been  generally  recognized  as  the  best  and  most  practical,  and  it  forms 
the  basis  of  the  classifications  in  use  to-day.  In  Europe  the  Inter- 
national Anti-Tuberculosis  Association  has  modified  it  by  adopting  part 
of  the  scheme  of  Gerhardt  ('01),  and  in  this  country  the  iSIational  Asso- 
ciation has  used  it  as  the  basis  of  their  classification,  but  has  modified 
it  by  adding  to  it  certain  clinical  data,  while  Trudeau  has  a  system  of 
his  own  in  which  also  he  combines  anatomical  and  clinical  facts  in  classi- 
fying his  cases.  It  is  probable  that  the  system  of  the  International  Anti- 
Tuberculosis  Association,  more  or  less  modified,  will  finally  be  universally 
adopted,  and  hence  it  should  be  familiar  to  all  workers  in  this  line. 
While  retaining  the  anatomical  basis  of  Turban's  scheme  almost  entirely, 
this  so-called  Turban-Gerhardt  scheme  modifies  it  by  noting  the  condition 
of  each  lung  separately,  and  makes  one  or  two  other  slight  changes.  Kay- 
serling,  speaking  of  it,  says  that  "  this  is  a  material  improvement,  as  one 
thereby  gets  immediately  a  plastic  image  of  the  case  in  hand ;  especially 
in  studying  results  is  it  a  great  advantage  that  we  know  of  each  case — 
which  side  of  the  lung  is  diseased,  and  to  what  degree — for  only  thus  is 
it  possible  at  a  reexamination  to  determine  if  the  cure  is  persisting." 

While  in  Turban's  original  scheme  the  first  stage  was  limited  to 
changes  of  the  volume  of  one  lobe  or  two  half  lobes,  in  the  new  it  is 
limited  to  changes  reaching  to  the  level  of  the  clavicle  in  front  and  the 
spine  of  the  scapula  behind,  save  in  cases  of  unilateral  trouble,  when 
the  second  rib  is  taken  for  the  lower  limit. 

Further,  in  the  new  classification  the  presence  of  considerable  cavi- 
ties places  the  case  in  the  third  stage,  and  the  stage  of  any  cases  must 
be  judged  by  the  condition  of  the  most  seriously  afl^ected  lung. 

The  jS'ational  Association  for  the  Study  and  Prevention  of  Tuber- 
culosis ap))ointed  a  committee  to  arrange  a  classification,  of  which  Y.  Y. 
Bowditch  and,  later.  Ij.  Brown  were  chairmen,  and  this  committee  has 
reported  a  classification  which  has  been  generally  adopted  in  this  coun- 
try, and  which,  while  based  on  the  scheme  of  Turban,  is  imjiroved  and 
amplified  by  the  addition  of  certain  clinical  data  without  which  they 
considered  his  scheme  scarcely  comprehensive  enough. 

Below  I  give  the  classifications  of  Turban-Gerhardt,  of  the  Xational 
25 


362 


DIAGNOSIS 


Association,  and  of  Trudeau  in  parallel  columns  for  ease  of  comparison. 
In  looking  over  these  the  excellence  of  Turban's  idea  is  evident,  and  it  is 
not  remarkable  that  it  has  been  popular,  but  the  clinician  in  using  it  will 
find  himself  hampered  by  its  failure  to  take  notice  of  the  clinical  condi- 
tion of  the  case,  which  is  of  such  paramount  importance  in  classifying  it. 

The  anatomical  condition  alone  cannot  by  itself  give  us  a  complete 
idea  of  the  state  of  the  case;  daily  one  sees  patients  with  quite  extensive 
signs,  who  are  yet  in  excellent  general  condition  and  with  practically 
no  symptoms,  while  some  very  severe  cases  can  have  very  scanty  phys- 
ical signs.  Indeed,  were  we  obliged  to  use  only  one  or  the  other,  I 
believe  we  would  find  that  symptoms  are  usually  a  safer  guide  to  a 
patient's  condition  than  signs,  and  I  do  not  believe  that  any  classifica- 
tion for  general  use  can  omit  certain  clinical  data  from  its  plan. 

If  the  physician  will  use  a  proper  system  of  classification  he  will 
find  it  an  easy  matter  to  divide  his  cases  into  three  stages,  botli  in  the 
commencement  and  at  the  end  of  treatment,  and  it  is  earnestly  to  be 
hoped  that  all  physicians  in  reporting  cases  in  the  medical  press  will 
be  careful  to  classify  them  in  this  wav. 


Turban-Gerhardt 


Disease  of  slight  se- 
verity, limited  to  small 
areas  of  one  lobe,  that, 
for  instance,  in  case 
of  affection  of  both 
apices,  may  not  extend 
beyond  the  spine  of  the 
scapula  and  the  clav- 
icles; in  case  of  affec- 
tion of  one  apex,  fron- 
tal, beyond  the  second 
rib. 


National  Association 
7.  Incipient  (fnvorahle) 

Slight  initial  lesion 
in  the  form  of  infil- 
tration, limited  to  the 
apex  or  a  small  part  of 
one  lobe. 

No  tuberculous  com- 
plications, slight  or  no 
constitutional  symp- 
toms (particularly  in- 
cluding gastritis  or  in- 
testinal disturbances  or 
rapid  loss  of  weight). 
Slight  or  no  elevation 
of  temperature  or  ac- 
celeration of  pulse  at 
any  time  during  the 
twenty-four  hours,  es- 
pecially if  at  rest. 
Expectoration  usually 
small  in  amount  or  ab- 
sent. Tubercle  bacilli 
may  be  present  or  ab- 
sent. 


Trudeau 

7.  Incipient 

Cases  in  which  both 
the  physical  and  ra- 
tional symptoms  point 
to  but  slight  local  and 
constitutional  involve- 
ment. 


ON  THE   RECOGNITION   OF   STAGES 


363 


Turbax-Gerhardt 

// 

Disease  of  slight  se- 
verity,' more  extensive 
than  I,  but  affecting  at 
most  the  volume  of  one 
lobe;  or  severe  disease,^ 
extending  at  most  to 
the  volume  of  one  half 
lobe. 


National  Association 

77.  Moderately 
Advanced 

No  marked  impair- 
ment of  function, 
either  local  or  constitu- 
tional. Localized  con- 
solidation, moderate  in 
extent,  with  little  or  no 
evidence  of  destruction 
of  tissue.  Or  dissem- 
inated fibroid  deposits. 
No  serious  tuberculous 
complications. 


Trudeau 

77.  Advanced 

Cases  in  which  the 
localized  disease  proc- 
ess is  either  extensive 
or  in  an  advanced 
stage,  or  where,  with 
a  comparatively  slight 
amount  of  pulmonary 
involvement,  the  ra- 
tional signs  point  to 
grave  constitutional 
impairment  or  to  some 
complication. 


777 


777.  Far  Advanced 


III.   Far  Advanced 


All  cases  extending 
beyond  II,  and  all  such 
with  considerable  cavi- 
ties. 


Marked  impairment 
of  function,  local  and 
constitutional.  Local- 
ized consolidation,  in- 
tense or  disseminated 
areas  of  softening,  or 
serious  tuberculous 
complications. 


Cases  in  which  both 
the  rational  and  phys- 
ical signs  warrant  the 
term. 


•  By  disease  of  slight  severity  is  to  be  understood:  disseminated  ff)ci  manifested 
by  slight  dullness,  impure,  rough,  feeble,  vesiculobronchial  or  bronchovesiciilar 
breathing,  and  fine  or  medium  riiles. 

2  By  severe  disease  is  to  be  understood:  compact  infiltration,  recognized  by 
great  dullness,  very  weak  bronchovesicular  or  bronchial  breathing  with  or  without 
rales.  Considerable  cavities,  to  be  recognized  by  tympanitic  sound,  amphoric 
breathing,  and  extensive  coarse  consonating  rales,  come  under  Stage  III.  Pleu- 
ritic dullness,  if  only  a  few  centimeters  in  extent,  is  to  be  left  out  of  account;  if 
it  is  extensive,  pleuritis  should  be  especially  mentioned  under  tuberculous  compli- 
cations. 

The  stage  of  the  disease  is  to  be  indicated  for  each  side  separately.  The  case 
as  a  whole  is  to  be  classified  according  to  the  more  diseased  side.  For  example, 
R  II,  L  I  =  Stage  n. 


364  .  DIAGNOSIS 

CONDITION    ON    ARRIVAL    AND    ON    DISCHARGE 

(National  Association) 

A.  On  arrival: 

1.  Extent  of  Disease.     (Pvit  here  Turban's  scale  or  Turban-Gerhardt.) 

2.  How  long  sick? 

3.  General  condition :   (a)  favorable;  (h)  unfavorable. 

4.  Digestion:   (h)   unimpaired;   (y)   impaired. 

5.  Pulse  (rate). 

G.     Temperature:    (E.)   101°  F.  or  over;    (F.)   99°  to   101°   F.;    (N.) 
Normal. 

7.  Bacilli:   (+)  present;   (0)  absent.' 

8.  Tuberculous  complications. 

9.  Other  complications. 

10.     Classification  of  case.     (Here  put  National  Association  classifica- 
tion.) 

B.  On  discharge: 

Progressive.  (Unimproved.)  All  essential  symptoms  and  signs  un- 
abated or  increased. 

Improved.  Constitutional  symptoms  lessened  or  absent,  physical  signs 
improved  or  unchanged,  cough  with  bacilli  usually  present. 

Arrested.  Absence  of  all  constitutional  symptoms,  expectoration  with 
bacilli  absent  or  not,  physical  signs  stationary  or  retrograding. 
This  for  at  least  three  months. 

Apparently  cured.  All  constitutional  symptoms  with  expectoration 
and  bacilli  absent  for  three  months,  signs  of  healed  lesions. 

Cured.     Same  for  two  years  under  ordinary  conditions  of  life. 
(Also  note  A  3  to  A  9  inclusive.) 


'Wilson  of  Baltimore  has  well  suggested  A'^,  "  no  sputum  examination  made," 
to  cover  the  large  number  of  cases  in  which  this  has  been  neglected. 


filOcfj/teJ  /rvm   ^/ovsse/ 


Figs.  84  and  85. — Suspect  Case  in  Anemic,  Slender  Youth.     No  fever.     Slight  cough. 
No  expectoration.     (Case  E.  Z.) 


TVToc// ^/eJ  from  tJocss-ef 

6.k^.  'OS" 


?r)<idi/i'e<S  Jnni  >/o^SSC/. 


Figs.  86  and  87. — Incipient  Case.  Four  months'  course.  BacilH  present.  General 
condition  favorable.  Digestion  unimpaired.  Temperature  normal.  Pulse  80. 
(Case  C.  D.) 

365 


IVTodi  1^ leJ  from  (Joessc/ 

C.IM-  'oS" 


7n<>t////'eJ  /rem  \/oesse/. 


Figs.  88  and  81). — Incipient  Case,  Chiefly  Posterior,  Extent  I.     Note  slight 
pleurisy  under  left  scapula.     (Case  Y.) 


■  TVod i f  leJ  from  cfoessef 

CLM.   'OS" 


Figs.  90  and  91.— Stage  I.     (Case  G.  B.) 


363 


Tnodi/ifi  /rtm  Joesst 

TVTod i f  leJ  from  fJoGssel 

'  CA-M-  'o^ 

Figs.  92  and  93.— Stage  I.     (Case  F.  K.  S.) 


JVod I  f  leJ  from  tJoQSSel 

C.i-M.  'OS" 


?noj,/ieJ  /ior»  Joeae/. 


Figs.  94  and  95, 


—Incipient  Bilater.^l  Case.     (Case  X.) 


367 


TVTod I  f  led    from  tJoGS-^el 

'  C.l^l   'OS- 


/ne</,//eJ ^rtm  t/oeise/. 


Figs.  96  and  97. — Incipient  Case,  but  with  Disseminated  Lesions  and  Laryngeal 

Involvement.     (Case  W.  B.) 


VR-f 


TVTodifisJ  from  t/oesse/ 

CLM.  'oS" 


?nac/f/iei /rtnt  i/oesse/. 

Figs.  98  and  99.— Stage  II.     (Case  Mrs.  W.) 


368 


VR-^ 


Figs.    I'JO  and   101.— Stage  II.     Left  Basal  Pleurisy  and  Limited  Motion. 

(Case  R.  S.  W.) 


TVToc/i f  leJ   from  tjoeiief  11/  ,        - 

ClM    'Of  ^<&,/,eJ  />„„,  Joesse/ 

* 

Figs.  102  and  103. — Stage  II.     Of  Long  Duration  with  Retrogressions  and 
Exacerbations.     (Case  J.  L.  W.) 

369 


TVTodifieJ  fronx.fjoessel 

C.ZA/.  v^r. 


Figs.  104  and  105. — Stage  II.     Beginning  Softening,  Later  Excavation. 

(Case  W.  G.  B.) 


^o</i//eJ  /rtni  ^/ofSSe/. 


Ci./^    'OS' 
Fig.s.  106  and  107. — Stage  II.  (possibly  III.),  Beginning  Softening.     (Case  E.  M.) 
370 


JVTod, fie<^  from  (Joesse/ 


^adi/ifj  /i-tm   ^/oeSie/ 


Figs.  108  and  109. — Stage  III.  (Left),  I.  (Right).    Fibroid  Phthisls.    Unfavorable  con- 
dition.   Temperature  norinai.     Bacilli  present.     Note  dislocation  of  heart.     (Case  R.  S.) 


Vf^ 


VR# 


JVodifieJ  from  Ooessc/ 

CLM.  '05 


7l'itdi/if4 /fm  \/ofSie/. 


Figs.  110  and  111. — Stage  III.     Softening  of  Consolidated  Right  Apex.     (Case  Z.) 

371 


Ivrod/'fieJ  fromcToesse/  '        '^ 7no,/,/,e<l //•«»,  Joes se/. 

C.l.M-  'OS" 

Figs.  112  and  113.— Stage  III.  (R.  III.,  L.  I.).     Cavity  R.  U.  A.     (Case  G.  P.) 


Figs.  114  and  115.— Stage  III.     Cavity  (R)  and  Fluid  at  Base  (L).     (Case  C.) 
373 


VR-I 


TVTodifieJ  from  (Joessel 


^"cfz/zeJ  //oni  Joesse/. 


Figs.  IIG  and  117. — St.^ge  III.     Rapidly  Spreading,  Softening.     Obstinate  fever, 

reduced  by  rest.     (Case  H.) 


TVTodi fieJ  from  (Joessef 

CAM.  'OS" 

Figs.  118  and  119. — Acute  Tuberculous  Pneu.vionia,  Stage  III.,  Illness  Six  Weeks. 
Hopeless.     Note  retractions  at  apices.     (Case  B.  I.) 

373 


DIAGNOSIS 


TVodifieJ  front  (Joesse/  ^odi/iei />»ni  Joesif/. 

CIM.  '05" 

Figs.   120  and  121. — Acute  Miliary  Tuberculosis.     Three  months'  duration. 
Just  before  death.     (Case  Mrs.  S.) 


ON  RECORDING   FINDINGS 

If  we  are  to  classif}'  all  our  cases  carefully  it  is  very  important  that 
there  sliould  be  some  uniformity  in  recording  our  findings.  For  this 
purpose  the  physician  should  have  good  outlines  of  the  anterior  and 
posterior  aspects  of  the  chest  on  which  graphically  to  record  the  con- 
dition of  the  lung,  as  well  as  charts  of  the  mouth,  nose,  and  larynx  for 
recording  the  condition  of  tlicse  parts.  It  is  better  to  have  these  all  on 
one  sheet  of  paper,  on  the  other  side  of  which  are  spaces  for  the  facts 
noted  on  inspection,  palpation,  and  mensuration.  Personally  I  prefer 
three  chest  outlines — one  for  fluoroscopy,  one  for  percussion,  and  one 
for  auscultation — since  this  gives  ample  room ;  but  if,  as  Trunk  advises, 
we  use  the  pencil  for  recording  percussion  and  the  pen  for  recording 
auscultation,  both  can  be  recorded  on  one  diagram ;  hut  fluorosco]jy 
needs  a  separate  one,  on  which  shadows,  limitations  of  outlines  and  of 
motion,  etc.,  can  be  noted. 

The  chest  diagrams  here  given  I  have  based  on  the  standard  ana- 
tomical works  of  Poirier-Charpy  and  of  Joessel.  The  upper  inner  apex 
outline  is  better  given  as  concave  above  and  convex  below,  rather  than 
as  in  the  charts,  but  any  such  small  details  can  easily  be  changed  in 


ON  RECORDING   FINDINGS  375 

an}'  diagrams  for  which  the?e  charts  serve  as  a  basis,  and  from  experi- 
ence I  can  recommend  them  as  not  onl)'  correct,  but  conveniently  large, 
tlie  fault  of  using  too  small  a  diagram,  and  thus  crowding  our  findings, 
being  one  to  be  avoided. 

The  facts  to  be  noted  under  inspection  are :  General  build ;  nourish- 
ment, complexion,  and  skin;  eyes,  hair,  and  nails;  teeth,  gums,  and 
tongue,  dyspnea;  glands,  heart,  stomach,  respiratory  motion,  form  of 
chest — its  length,  breadth,  and  depth.  Under  palpation,  vocal  fremitus 
in  the  different  parts  of  tbe  chest,  and  the  condition  and  rate  of  the 
pulse  and  the  apex  beat.  I'nder  mensuration  should  be  noticed  degree 
of  the  temperature,  height,  weight,  and  vital  capacity,  and  tape  meas- 
urements, and  there  should  be  a  line  on  each  side  of  wliich  to  lay  out 
the  lead-tape  tracings  of  the  two  halves  of  the  chest.  There  should  also 
be  on  this  chart  the  condition  on  arrival  and  on  discharge,  according 
to  the  scheme  of  the  Xational  Association,  as  already  given.  So  much 
for  the  physical  examination  chart.  Turning  to  methods  of  recording 
the  findings,  the  graphic  method  is  now  so  generally  used  that  its 
advantages  need  not  be  dwelt  upon  liere.  Enough  to  say  that  it  gives 
at  a  glance  the  condition  of  the  physical  signs,  enables  us  to  compress 
much  information  into  a  small  space  and  to  localize  the  various  signs 
far  more  sharply  than  can  be  done  if  we  try  to  describe  them  in  writing. 
Probably  the  l)est-known  system  of  signs  is  that  of  Sahli.  But  desirable 
as  it  is  that  all  should  use  a  similar  notation  if  possible,  this  system 
has  some  faults  and  has  been  variously  modified  by  different  clinicians. 
Probably  every  man,  whatever  plan  he  follows  in  the  main,  will  modify 
it  in  particulars  to  suit  his  own  ideas,  and  the  system  I  have  devised, 
while  being  both  simple  and  convenient,  is  given  chiefly  as  a  suggestion 
to  others  in  developing  their  own  systems.  It  is  based  in  part  on  that 
of  Sahli,  and  especially  on  the  excellent  plan  of  Trunk.  Whatever 
signs  we  use  must  be  capable  of  being  easily  and  quickly  drawn,  must 
be  unlikely  of  confusion  with  other  signs,  and  must  not  be  too  complex. 
The  percussion  findings  are  noted  by  shadings  of  various  intensity,  the 
limit  of  dullness  being  marked  by  a  heavier  line,  but  I  have  added 
"  Slit."  for  short  percussion  note  and  "  Impd."  for  impaired  resonance, 
neither  of  which  can  be  indicated  by  shadings,  and  both  of  which  are 
of  diagnostic  importance. 

Under  auscultatory  signs  I  have  adhered  to  the  rectangle  of  Sahli, 
the  vertical  limb  representing  inspiration,  the  horizontal,  expiration; 
but  as  in  hasty  drawing  it  is  very  easy  to  miscalculate  the  length  of 
the  base  line,  and  thus  to  make  expiration  appear  prolonged  when  it  is 
not,  I  have  added  a  hypotenuse  to  the  right  angle,  so  that  any  pro- 
longation beyond  the  normal  is  quickly  seen  and  easily  indicated.  More- 
over, since  the  heaviness  of  the  lines  is  used  to  indicate  the  intensity 


376  DIAGNOSIS 

of  the  breatli  sound  by  some,  the  thickness  of  this  hypotenuse  can 
serve  as  a  standard  of  thickness,  and  any  increase  or  decrease  of  the 
tliickness  of  the  other  two  lines  can  be  noted  by  comparison  with  this. 
Tiie  plan  of  indicating  the  pitch  of  the  expiratory  and  inspiratory 
sounds  by  the  angle  made  by  the  lines  with  the  horizontal,  which,  as 
far  as  I  know,  was  first  used  by  Page,  has  advantages,  but  cannot  be 
well  combined  with  Sahli's  right  angle,  and  as  the  other  is  simpler  and 
easier  of  use  I  have  adopted  it.  To  indicate  feeble  breathing  by  light 
lines  is  unadvisable,  since  mistakes  can  be  made  in  drawing  the  line, 
so  that  I  use  an  F  inscribed  in  the  triangle  for  this  purpose  as  clearer; 
but  to  indicate  puerile  breathing  I  use  a  triangle  with  all  three  sides 
very  heavily  marked,  which  cannot  be  mistaken.  Absence  of  breath 
sounds  is  very  easily  indicated  by  a  zero  inscribed  in  the  triangle. 

Sahli's  division  of  rales  is  that  of  Skoda,  which  is  used  in  Ger- 
many, but  which  has  not  Avon  acceptance  in  this  country  or  England, 
and  I  have  therefore  adhered  to  the  plan  of  dividing  rales  into  dry 
and  moist — as  they  are  given,  for  example,  among  others,  by  Cabot. 
The  part  of  the  respiratory  murmur  in  which  the  rale  occurs  can 
be  indicated,  if  desired,  by  a  vertical  line  at  the  side,  indicating  in- 
spiratory rales,  or  a  horizontal  one  in  the  same  location  to  indicate 
expiratory. 

To  indicate  whether  the  rale  occurs  only  on  deep  breath  or  only 
after  coughing,  a  d  or  an  !  can  be  written  at  the  side.  To  indicate 
whether  the  rtde  is  musical  (resonant,  consonant),  a  circle  (moist  ride) 
with  a  tail  to  it,  like  a  musical  note,  is  used  by  Trunk,  with  an  m  at 
the  end  of  the  tail  if  it  is  metallic. 

While  one  who  is  not  used  to  employing  such  signs  might  sup- 
pose them  to  be  complex  and  troublesome,  a  short  experience  of 
them  will  convince  anyone  of  their  ease  of  application  and  conven- 
ience, while  their  import  can  be  understood  fully  as  quickly  as  the 
written  words. 

A  good  point  made  by  Trunk  is  the  use  of  pencil  to  mark  per- 
cussion findings  and  of  the  pen  to  mark  auscultation  findings.  Pen  and 
pencil  ai^  always  at  hand  and  are  more  satisfactory  than  the  red  and 
blue  pencils  recommended  to  distinguish  percussion  findings  by  Sahli — 
blue  for  dullness,  red  for  flatness,  with  mixtures  for  intermediate  de- 
grees. Preceding  the  scheme  of  signs  for  recording  physical  findings 
will  be  found  a  few  typical  charts  to  exemplify  their  use,  as  well  as 
to  show  the  different  stages  according  to  the  Turban-Gerhardt  classi- 
fication. 


SIGNS   FOR   RECORDING   PHYSICAL   FINDINGS 
Percussion  Signs  (to  be  made  in  pencil) 


T^  r  J  n  sht.   Short  note. 

Degrees  or  dullness. 

•    (Xote  lower  or  upper  linnt,  ^^'^'  Impaired  resonance. 

of  dullness  by  heavier  line.)  h.  R.  Hyperresonance. 


Flatness. 


c .  p.  "  Cracked-pot ' '  resonance. 
T    Tympany. 


fMotion  of  base. 

|,     IK      ^      (Amount  can   be  noted   in 

Uches.)  (g)  Wintrich's  change. 

'(3  Motionless  base. 


|\  Vesicular  murmur. 

|\  Puerile  breathing. 

A  Feeble  breathing. 

|\  Absent  breath  sounds 


Auscultation  Signs  (to  be  made  in  ink) 

Vesiculobronchial. 


Bronchovesicular. 
Bronchial. 


^  Cavernous. 
|v^  1^   Rough  (granular,  "rude"),    k      ^^^^^^.^  ^^.^^^^.^^ 

\         Prolonged  expiration. 
.      k      »       Inspiratory,    expiratory, 


Heart  sounds  unduly  trans- 
n        mitted. 


nspiratory  and  expira- 
tory harsh  breathing. 


K     K       Cogwheel  (interrupted) 
I  \  i_\         breathing. 

|\     Inspiration  interrupted. 


Vyp   Whispered  pectoriloquy. 

VR  +  Increased   1 

I  Vocal 
VK  -  Decreased  j      resonance. 

\/"R  o  Absent      J 
A   Aegophony. 


377 


SIGNS   FOR   RECORDING  PHYSICAL  FINDINGS— CoTifmuerf 

Adventitious  Sounds 
Dry  Rdles 

'  \'      Dry  crackles  (isolated  crepitations). 

« 

.;/.;•;:;      Crepitant  rales. 
^xx**     Medium  dry  rales. 

xl  I 

x-^\  \    Large  dry  rales.  Inspiratory.  I  Expiratory. 

Moist  Rdles 

/o",        °Q  oo     Fine  and  medium  (subcrepitant)  rales. 

0 

qO  o  ^ 

o^rk    Large  moist  rales. 

*]  9  Cj  Resonant  (consonant,  musical).   \^^  Metallic. 

%,0    Gurgles. 

ojl^     "  Mucous  click. " 

s        Sibilant  rales. 
3      Sonorous  rales. 

dl      Rales  on  deep  breathing  only,     f     Rales  after  cough  only. 
Ill     Fine  friction  sounds.  Ill  Loud  friction  sounds. 

378 


ADDENDA  379 


ADDENDA 


Summary  of  Symptomatology  and  Diagnosis  Presented  at   the  Inter- 
national Congress,  held  in  Washington,  D.  C. 

Landoiizy  reported  on  that  form  of  acute  tuberculosis  first  described 
by  himself  as  "  typhobacillose/"  and  which  has  already  been  alluded 
to.  He  distinguishes  it  from  caseous  bronchopneumonia  and  from, 
acute  miliary  tuberculosis.  No  miliary  granulations  are  to  be  found. 
There  are  no  localizing  symptoms,  either  pulmonary,  cerebrospinal, 
or  abdominal,  and,  instead  of  being  always  rapidly  fatal,  it  usually 
ends  in  recovery,  so  far  as  the  generalized  acute  infection  is  con- 
cerned. In  the  majority  of  cases,  after  three  or  four  weeks  of  con- 
tinuous fever,  tlie  patient  convalesces,  l)ut  only  imperfectly.  Appetite 
does  not  return.  Emaciation  continues,  and  finally  the  localizing  signs 
of  tuberculosis  appear — usually  in  the  lungs  or  pleura,  or,  in  cluldren, 
in  the  mesentery.  Occasionally  a  good  convalescence  follows  such 
attacks,  but,  sooner  or  later,  tuberculous  lesions  appear.  Usuf^lly,  how- 
ever, after  the  fever  sul)sidcs,  the  patients  continue  in  a  state  of  latent 
tuberculosis,  and  in  a  few  weeks,  months,  or  even  years  after  the  initial 
acute  septicemia  they  are  found  to  be  tuberculous.  He  would  distin- 
guish it  from  typhoid  fever  by  the  irregularity  of  tlie  fever  curve,  which, 
wliile  continuous,  shows  greater  oscillations;  secondly,  by  a  lack  of  cor- 
respondence between  the  pulse  and  the  temperature — the  pulse  being 
faster  than  in  typhoid  fever;  thirdly,  by  an  absence  of  visceral  symp- 
toms; and,  lastly,  by  absence  of  rose  spots.  Its  diagnosis  from  typhoid, 
as  which  it  usually  masquerades,  can  only  be  made  by  the  use  of  labora- 
tory methods,  such  as  the  Widal  test. 

Symptoms. — A^on  Vnterberger  does  not  consider  a  small  heart  as 
predisposing  to  tuberculosis,  but  believes  that  the  rapid  enlargement  of 
this  organ  in  phthisis  is  related  to  a  congenital  ])redisposition  and  is 
caused  by  an  obstruction  to  the  lesser  circulation  and  l)y  the  toxins  of  the 
bacillus  and  of  the  products  of  metal)olism.  He  believes  that  an  en- 
larged heart  and  liver  form  a  very  im])ortant  link  in  the  chain  of  early 
clinical  symptoms. 

Ullom,  as  a  result  of  the  study  of  the  livers  of  those  dying  from 
tuberculosis  in  the  Phi])))s  Institute,  notes  that  miliary  tubercles  are 
found  in  a  majority  of  cases  of  chronic  phthisis.  Solitary  tubercles  were 
rare,  while  passive  congestion  was  found  in  nearly  every  case,  but  amy- 
loid and  fatty  changes  were  found  in  a  relatively  small  number.  He 
does  not  believe,  as  tlic  result  of  his  observations,  that  fibrosis  or  cir- 
rhosis, due  to  the  bacillus,  occurs. 

J.  Anders,  in  a  paper  on  the  symptomatic  value  of  hemoptysis  in 


380  DIAGNOSIS 

early  tuberculosis,  notes  that  cases  of  hemorrhage  in  which  all  other 
clinical  and  laboratory  findings  are  negative  are  to  be  regarded  as  tuber- 
culous until  disprovcn.  It  is,  however,  not  pathognomonic,  but,  never- 
theless, of  exceptional  diagnostic  imj)ortance  as  a  cardinal  symptom.  In 
3,506  cases  of  tuberculosis,  9.6  per  cent  hemoptysis  was  noted  at  the 
very  commencement  of  the  disease,  and  in  cases  of  chronic  pulmonary 
tuberculosis  hemorrhage  was  one  of  the  most  characteristic  symptoms 
in  25  per  cent.  II.  von  Schrotter  (Vienna)  reported  on  the  occurrence 
of,  usually  undiagnosticated  pneumothorax  without  exudate  in  early 
tuberculosis.  This  can  best  be  studied  by  the  use  of  the  X-ray  and  the 
spirometer.  A  deficiency  in  vital  capacity  of  1,000  to  1,500  c.c,  espe- 
cially in  a  case  whose  normal  vital  capacity  is  already  known,  permits, 
he  believes,  a  diagnosis  of  latent  pneumothorax,  even  if  other  signs  are 
doubtful. 

Ticry  and  Eenoux  found  that  the  scales  of  pityriasis  versicolor  in- 
oculated into  guinea  pigs  caused  tuberculosis,  while  the  scales  taken 
from  healthy  skin  of  consumptives  or  from  other  dermatoses  failed  to 
do  so.  This,  if  urefied,  would  suggest  that  this  skin  disease  is  specifi- 
cally tuberculous. 

Metabolism. — Croftan  spoke  of  the  increased  urinary  calcium  excre- 
tion in  tuberculosis.  This  he  would  explain  by  an  affinity  between  the 
calcium  and  an  albumosc  which  is  almost  universally  present  in  tuber- 
culous foci,  sputum,  culture  media,  blood,  and  urine.  When  rendered 
calcium-free  it  has  marked  fever-producing  qualities  which  it  loses  when 
again  combined  with  calcium.  The  combination  he  regards  as  a  pro- 
tective anti])yretic  process  which  would  suggest  therapeutic  possibilities. 

Diagnosis, — The  ophthalmic  reaction  (Wolff-Eisner,  Calmette)  was 
the  subject  of  valuable  reports  by  Calmette,  Wolff-Eisner,  Baldwin, 
Malmstrom,  Bailliart,  and  by  F.  Arloing.  Xone  of  these  observers  con- 
sider the  test  dangerous  to  the  healthy  nontuberculous  eye,  and  it  is 
probable  that  the  bad  results  which  have  been  reported  (see  text)  were 
due  to  its  use  in  tuberculous  eyes.  Calmette,  in  6,603  cases,  had  no 
serious  results,  and  only  3  of  phlyctenular  keratitis,  20  of  conjunc- 
tivitis, and  72  slow,  persisting  reactions.  Wolff-Eisner  considers  it 
absolutely  without  danger  if  contraindications  are  observed.  Baldwin 
thinks  that,  used  with  proper  precautions,  the  danger  is  slight,  and 
Arloing,  Jr.,  notes  that  its  possible  bad  effects  can  be  largely  obviated 
by  a  preliminary  instillation  of  adrenalin,  1:3,000. 

Diagnostic  Value. — The  percentage  of  positive  reactions  in  active 
tuberculosis  was  placed  by  the  various  writers  and  speakers  at  from 
70  to  96  per  cent.  Trimescu  placed  it  at  96  per  cent.  Calmette,  in 
2,894  cases,  at  92  per  cent.  Wolff-Eisner  stated  that  85  per  cent  will 
react;  Malmstrom,  86  per  cent;  and  Baldwin,  from  a  study  of  310  cases. 


ADDENDA  381 

70  per  cent.  White  and  McCampbell  reported  on  its  use  in  cattle,  and 
note  that,  since  repeated  instillations  create  a  hypersensibility,  the  result 
of  the  first  instillation  alone  should  be  made  the  basis  of  diagnosis. 
They  consider  that  a  proper  reaction  in  ten  or  twelve  hours  demonstrates 
tuberculosis.  The  views  as  to  its  diagnostic  reliability  varied.  AVolff- 
Eisner  held  that  it  will  be  positive  only  in  the  presence  of  active  tuber- 
culosis, and  Calmette  stated  that  a  positive  reaction  to  the  ophthalmic 
and  cutaneous  tests  furnishes  almost  conclusive  evidence  of  the  existence 
of  an  active  tuberculous  focus.  He  found  early  reactions  chiefly  in 
suspected  tuberculosis,  late  or  slight  ones  chiefly  in  well-developed  tuber- 
culosis, and  he,  like  all  others,  has  found  that  advanced  cases  react 
slightly  or  not  at  all.  He  says  that,  unlike  the  cutaneous  reaction,  it 
seems  to  be  found  chiefly  in  active  or  developing  foci,  and  not  with 
healed  lesions,  and  believes  that,  used  in  children  over  one  year  of  age, 
it  shows  active  tuberculosis.  Baldwin  considers  that  the  test  has  some 
value  in  confirming  the  diagnosis  in  its  early  stages,  but  slight  value 
when  the  symptoms  justify  only  a  suspicion.  Its  value  in  distinguishing 
active  latent  from  healed  tuberculosis  he  regards  as  undecided.  He 
would  confine  its  use  to  adults,  since  the  cutaneous  test  is  equally 
valuable  for  children,  and  would  restrict  the  subcutaneous  test  to 
cases  where  a  focal  reaction  is  desired  and  where  the  ophthalmic  and 
cutaneous  tests  have  been  negative.  Malmstrom  considers  it  diagnostic 
and  useful,  but  not  final ;  while  F.  Arloing  regards  it  as  a  convenient 
diagnostic  measure  whose  value  is  not  absolute. 

Prognostic  Value. — Here,  again,  views  vary.  Baldwin  regards  the 
ophthalmic  as  unreliable  for  this  purpose,  while  Wolff'-Eisner  considers 
its  prognostic  value  to  be  very  great  and  thinks  that  the  failure  of  the 
cutaneous  and  conjunctival  reactions  is  prognostically  unfavorable,  as 
is  also  a  rapid  (twenty-four  hours  in  all)  reaction,  while  a  permanent 
reaction  (seven  to  twenty  days)  he  considers  favorable  and  occurring 
chiefly  in  healed  tul)erculosis.  Calmette  thinks  that  as  bad  cases  react 
slowly  (forty-eight  hours),  weakly,  or  not  at  all,  and  light  ones  strongly, 
the  test  has  prognostic  value.  However,  he  calls  attention  to  tiie  fact 
that  since,  after  five  days,  hypersusceptibility  (anaphylaxis)  is  estab- 
lished, which  lasts  for  twenty-five  or  thirty  days,  we  should  repeat  the 
test  before  the  fifth  day.  He  also  notes  that  cases  taking  tuberculin 
do  not  react  until  one  month  after  the  injections  are  stopped.  Trimescu 
(Bukarest)  made  the  interesting  statement  that  while,  as  is  well  known, 
severe  cases  are  generally  negative,  they  can  become  positive  if  the 
process  improves  and  gets  less  active.  F.  Arloing  reported  that  he  had 
found  that  the  reaction  is  caused  not  only  by  the  presence  of  tubercle 
toxins,  but  also  by  those  of  typhoid,  diphtheria,  and  staphylococcic  and 
streptococcic  infections.     This  he  ascribes  to  the  vasodilator  effect  of 


382  DIAGNOSIS 

these  toxins  on  the  vasomotor  centers,  and  considers  tliat  it  shows  a 
state  of  intoxication  of  some  sort,  but  not  necessaril}^  tuberculous.  The 
reaction  in  tuberculosis,  in  his  o])inion,  shows  tliat  the  organism  is 
intoxicated  by  tuberculin,  and  he  considers  that  the  intensity  of  the 
reaction  indicates  the  degree  of  immunity  of  the  individual,  and  hence 
is  prognostically  valual)le.  As  to  the  physiology  of  the  test,  Calmette 
considers  the  reaction  to  be  due  to  the  fixation  of  the  tuberculin  by  the 
cells  rich  in  lecithin  and  to  the  reaction  between  the  two.  He  believes 
that  the  presence  of  free  lecithin  in  the  blood  has  a  close  relation  to 
tuberculosis,  as  the  suprarenals  are  always  congested  in  animals  killed 
by  tuberculin,  while  animals  refractory  to  tuljerculin  have  no  free  leci- 
thin in  tiieir  blood.  Finally,  lie  very  wisely  notes  that  these  tests  must 
not  be  overvalued,  but  tliat  all  other  clinical  and  laboratory  methods 
must  be  cautiously  and  wisely  used. 

The  Cutaneous  Reaction. — Von  Pirquet  believes  that  from  a  positive 
reaction  the  presence  of  tuberculosis  can  be  concluded.  The  reaction, 
however,  does  not  prove  that  the  patient  is  sick — i.  e.,  has  active  tuber- 
culosis— but  possibly  only  latent  trouble,  and  lie  warns  against  treating 
a  patient  for  active  tuherciilosis  on  the  strength  of  reaction  to  his  test. 
It  occurs  cliiefly  in  sliglit  or  inactive  tuberculosis,  and  in  Vienna  most 
grown  children  and  adults  react.  He  believes,  therefore,  that  in  adults 
only  a  severe  reaction  on  the  first  attempt  has  any  significance,  and  that 
in  this  case  it  speaks  for  a  new  process.  Repeated  failure  to  react,  in 
his  opinion,  excludes  tuberculosis.  Its  chief  value,  he  believes,  lies  in 
children  from  one  to  five  3'ears  of  age.  Calmette  considers  it  chiefly 
valuable  in  cases  of  calcified  and  healed  lesions  and  in  children  under 
one  year  of  age,  of  whom  about  twenty  per  cent  react.  After  this  age 
the  number  reacting  increases  rapidly,  and  over  fifteen  becomes  sixty  per 
cent,  while  nearly  all  adults  react,  so  that  he  would  limit  its  use  to 
children  under  one  year.  A  positive  reaction  to  both  ophthalmic  and 
cutaneous  tests  he  considers  almost  conclusive  evidence  of  an  active 
tuberculous  focus.  LeFetra  considers  a  positive  skin  reaction  in  infants 
almost  certain  evidence  of  tuberculosis,  and  if  a  careful  sputum  exami- 
nation and  skin  test  are  l)olh  negative,  he  thinks  we  can  feel  safe  in 
ruling  out  tul)erculosis.  Detre,  of  Budapest,  read  a  paper  on  his  method 
of  differential  bovine  and  human  cutaneous  tests,  with  old  tuberculin 
and  with  l)ouillon  filtrate  of  human  and  another  of  bovine  bacilli. 
He  reports  that  ninety-five  per  cent  of  all  tul)erculous  cases  react 
to  the  human  test  and  that  most  pulmonary  cases  are  of  this  class, 
while  in  children  and  in  visceral  and  bone  tul)erculosis  thirty  to 
forty-five  per  cent  react  to  the  bovine,  while  a  good  number  react 
to  both.  He  advises  testing  the  immunity  of  a  case  after  treatment 
by   a   large   dose   of   tuberculin,   after   a   cutaneous   test,   when   he  be- 


ADDENDA  383 

lieves  that  if  the  case  be  not  immune  the  cutaneous  reaction  will 
reappear. 

A  new  modification  of  the  tul)erculin  test  was  advocated  l)y  Mantoux 
(Cannes)  whicli  consists  of  an  intradermic  injection  of  tuberculin,  the 
needle  being  introduced  only  into  the  derma  as  in  cocainization.  The 
reaction  consists  of  a  macula  surrounded  by  a  bluish  zone,  and  he  con- 
siders his  modification  universally  reliable  in  active  tuberculosis.  The 
percutaneous  or  inunction  method  of  Moro  and  Lignieres  was  a  subject 
of  a  paper  by  the  latter,  but  nothing  new  was  brought  out. 

L.  Brown  reported  on  the  diagnostic  value  of  the  ophthalmic,  cutane- 
ous, and  subcutaneous  tests.  He  believes  the  cutaneous  method  has  no 
contraindications,  but  regards  the  conjunctival  test  as  offering  enough 
risk  of  severe  injury  to  the  eye  to  cause  him  to  be  opposed  to  the 
use  of  the  method.  As  to  the  subcutaneous,  he  has  "  used  it  in  a  large 
number  of  cases  for  eight  3'cars  "  and  has  "  yet  to  see  as  a  consequence 
anything  more  than  a  slight  temporary  untoward  result."  He  advocates 
a  procedure  in  the  use  of  these  tests  which  merits  general  acceptance. 
"  When  we  wish  to  apply  the  tuberculin  test  to  a  patient  presenting  sus- 
picious symptoms  or  physical  signs  of  tuberculosis,"  he  advises,  "  first 
to  use  the  cutaneous  test,  and  if  he  fail  to  react  with  this,  we  can  with 
some  degree  of  certainty  attribute  his  symptoms  to  some  other  disease. 
If  he  reacts  we  can  then  use  either  the  conjunctival,  when  no  contra- 
indications exist,  or  the  subcutaneous  method,"  in  which  he  places  still 
greater  confidence.  He  feels  "  that  the  conjunctival  test,  like  the  sub- 
cutaneous test,  should  be  used  onl}-  when  all  other  means  of  diagnosis 
have  been  exhausted."  Further,  he  notes  that  he  hesitates  to  say  "  that 
a  patient  does  not  react  to  the  tuberculin  test  until  the  subcutaneous 
test  has  been  found  negative."  He  believes  that  the  cutaneous  test 
reveals  very  accurately  both  active  and  latent  tuberculosis,  but,  since  the 
recognition  of  the  presence  of  inactive  and  encapsulated  foci  has  little 
clinical  significance,  the  cutaneous  test  alone  to  him  seems  to  possess 
slight  practical  value.  Hamman  concludes  as  to  the  use  of  tuberculin 
for  diagnosis  that  the  test  must  be  used  with  care  and  that  while  the 
reaction  is  believed  to  be  specific,  it  must  be  remembered  that  a  very  in- 
significant lesion  may  produce  tuberculin  hypersensitiveness.  A  negative 
reaction  he  considers  decisive  information,  as  also  a  focal  reaction. 

After  a  consideration  of  all  these  different  views,  it  is  evident  that 
the  conjunctival  and  cutaneous  tests  can  be  regarded  as  valuable  and 
safe  ^  additions  to  our  diagnostic  measures  and  as  fully  justifiable  pro- 

1  P.  Schnimpf  ('08)  concludes,  against  Teichmann  and  others,  that  the  ophthalmo 
reaction  can  lead  to  permanent  and  serious  lesions  of  the  eye  in  spite  of  all  measures 
of  precaution. — Editor. 


384  DIAGNOSIS 

cedures  in  properly  selected  cases.  They  iriay  at  times  render  un- 
necessary a  resort  to  the  rather  more  severe  subcutaneous  method,  but 
which  at  present  they  do  not  seem  entirely  to  supplant. 

The  diagnostic  value  of  the  opsonic  index  also  received  consideration. 
Inman  uses  the  test  to  demonstrate  autoinoculation,  either  spontaneous 
or  artificial  (after  exercise),  by  a  variation  in  the  opsonic  index  which 
does  not  occur  in  the  nontuberculous.  He  notes  that  the  tuberculous 
patient  who  exercises  is  elaborating  his  own  tuberculin.  A  rise  of  tem- 
perature goes  with  a  negative  opsonic  phase,  showing  autoinoculation, 
and  can  be  cliecked  by  absolute  rest.  Al)sence  of  variation  after  hard 
labor  he  regards  as  evidence  of  arrest,  but  some  of  these  cases  still  show 
bacilli;  hence  he  believes  he  is  justified  in  assuming  that  we  can  have 
arrest  of  the  disease  but  persistence  of  the  bacilli.  Sanborn  holds  simi- 
lar views  about  the  diagnostic  value  of  the  opsonic  index.  Szaboky 
considers  the  height  of  the  index  of  no  value,  but  thinks  that  lowering 
of  the  index  shows  the  presence  of  tuberculosis.  He  believes  that  it 
gives  an  approximate  idea  of  the  degree  of  immunity,  and  hence  is  a 
good  guide  for  treatment.  He  finds  it,  however,  troublesome  and  not 
giving  uniform  results,  the  personality  of  the  observer  having  a  great 
effect  on  the  counts.  M.  Lincoln  considers  that  the  great  skill  needed 
for  its  application  limits  its  utility.  She  finds  that  eighty  per  cent 
of  her  ophthalmic  and  cutaneous  tests  agree  with  the  opsonic  test.  The 
opsonic  index  was  positive  in  seventy-seven  per  cent  of  the  cases,  while 
the  tuberculin  test  was  positive  in  eighty  per  cent  of  the  same  cases. 

Other  Diagnostic  Methods. — Cade  advocates  the  study  of  the  cytol- 
ogy of  effusions  (Widal)  for  diagnostic  purposes,  in  determining  the 
nature  of  a  pleurisy,  predominance  of  lymphocytes  speaking  strongly 
for  tuberculosis.  In  other  than  pleural  effusions  its  value  is  doubtful 
except  in  ascites,  where  the  discovery  of  a  lymphocytosis  is  suggestive. 
Caution  and  control  by  other  methods,  however,  is  desirable.  Sondern 
has  examined  tlie  cerebrospinal  fluid  in  tuberculous  meningitis  in  chil- 
dren. He  considers  a  high  pressure  of  the  fluid  and  a  high  number  of 
lymphocytes  (eighty-six  per  cent)  suggestive.  If  bacilli  are  present  a 
relative  polynuclear  increase  may  indicate  a  mixed  infection,  while  if 
bacilli  are  absent  a  predominance  of  lymphocytes  should  encourage 
further  search.  M.  Solis-Cohen  has  studied  the  coagtdal)ility  of  the 
blood.  Persons  with  increased  coagulability  are  probably  less  liable, 
and  those  with  a  decreased  coagulability  more  liable,  to  hemorrhage.  In 
cases  with  hemorrhage  the  bleeding  ceased  more  quickly  in  those  with 
a  short  or  normal  clotting  time  than  in  those  in  whom  it  was  delayed. 
Bezancon  and  de  Jong  have  studied  the  behavior  of  the  cells  in  the 
sputum  of  caseous  tuberculous  pneumonia,  and  believe  that  a  tendency 
to  degeneration  of  the  cells    (j^olynuclear  and  young  pulmonary  epi- 


ADDENDA  385 

thelial  cells  usually  mononuclear)  is  the  most  marked  characteristic 
of  tuberculous  lesions,  and  is  especially  marked  in  galloping  consump- 
tion. They  found  pycnosis  of  the  polynuclear  cells  and  loss  of  staining 
quality. 

Arneth's  method  of  studying  the  nuclei  of  the  polynuclear  neutro- 
philes  was  the  subject  of  a  paper  by  Dluski  and  Kozpedzikowski.  They 
examined  55  cases  and  found  in  all  but  2  a  more  or  less  marked  impair- 
ment of  the  blood  picture,  with  displacement  to  the  left  up  to  75  per 
cent.  In  17  of  21  cases  examined  several  times  they  found  agreement 
between  the  picture  and  the  course  of  the  disease.  They  conclude  that 
tlie  method  may  do  good  service  in  the  clinical  study  of  the  disease  along 
with  other  methods.  Bushnell  reports  on  his  use  of  this  method,  which 
he  believes  to  be  of  distinct  prognostic  value.  He  regards  it  as  espe- 
cially useful  in  deciding  how  long  it  is  necessary  to  keep  the  patient 
quiet.  "  An  objective  proof  that  a  toxic  absorption  is  present  in  a 
degree  which  constitutes  a  tax  on  the  resistance  of  the  afebrile  patient 
is  one  of  the  great  desiderata  in  the  treatment  of  pulmonary  tuberculosis. 
Arneth,  it  appears  to  me,  has  furnished  the  means  of  securing  such 
proof  in  his  method  of  studying  the  neutrophylic  leucocytes." 

Sputum  Examination. — Much  calls  attention  to  the  fact  that  parts 
of  tuberculous  nodules  in  the  lungs  of  cattle,  in  which  the  microscope 
shows  no  acid-fast  bacilli,  produce  on  inoculation  into  guinea  pigs  typi- 
cal tuberculosis,  from  which  cultures  can  be  made.  Cold  abscesses  in 
human  beings  where  no  bacilli  can  be  demonstrated  by  Ziehl's  stain, 
give  cultures  by  the  inoculation  method,  and  by  a  modified  Gram  stain 
the  bacilli  can  be  made  visible  here  as  well  as  in  the  tissues.  The  more 
virulent  forms  of  bacilli  he  finds  most  easily  decolorized  by  the  acid. 
The  importance  of  this,  if  it  be  verified,  need  scarcely  be  dwelt  on. 

Physical  Diagnostic  Measures. — Few  new  procedures  in  this  line 
were  brought  forward.  Kuthy  noted  the  frequency  of  thoracic  pain 
of  pleural  origin,  AA-hich  he  found  present  in  60  per  cent  of  650  cases, 
and  in  85  per  cent  of  these  it  was  on  the  side  of  the  most  exten- 
sive lesion.  Seeking  for  an  objective  evidence  of  this  pain,  he  found 
it  in  the  "  clavicular  symptom,"  as  he  calls  it — i.  e.,  the  drooping  of 
the  outer  end  of  the  clavicle,  which  Aufrecht  has  specially  dwelt  upon. 
But  while  present  in  80  per  cent  of  the  first-stage  cases,  63  per 
cent  of  these  had  the  droop  on  the  most  affected  side,  and  in  20.5 
per  cent  of  all  cases  the  droop  did  not  correspond  to  the  affected  side. 
The  lessened  rise  or  immobility  of  the  acromion  on  the  affected  side 
he  calls  the  "  acromial  phenomenon,"  which  he  found  even  in  the  ear- 
liest cases;  80.4  per  cent  of  his  cases  showed  it  about  as  often  as  the 
"  clavicular  symptom,"  but  in  only  2  of  86  cases  did  it  not  correspond 
Avith  the  side  of  the  lesion.  He  concludes  that  pleural  pain  or  the  "  cla- 
26 


386  DIAGNOSIS 

vicular  symptom  "  indicates  the  diseased  side  with  al)out  80  per  cent  of 
probability,  while  the  "  acromial  phenomenon  ''  does  this  with  almost 
complete  certainty.  Franeke  believes  that  a  pain  on  pressure  in  incip- 
ient tuberculosis  to  be  found  where  the  inflammation  is  first  located — 
i.  e.,  in  the  posterior  superior  aspect  of  the  apices,  without  relation  to 
respiration — has  diagnostic  value.  He  lays  stress  only  upon  pain  pro- 
duced by  pressure  with  the  fingers  or  by  tapping  with  the  percussion 
hammer.  This  early  determination  of  a  pleurisy  accompanying  incip- 
ient tuberculosis  he  calls  "  algeoscopy."  The  pain  also  varies  directly 
with  the  extent,  advance,  or  retrogression  of  the  trouble,  its  depth  from 
the  surface,  and  its  cure.  In  77.5  per  cent  of  200  cases  he  found  this 
pain.  Of  these  154  were  light,  32  medium,  and  14  severe  cases.  Waller, 
in  a  paper  on  the  methods  of  percussion,  dwells  on  the  great  difficulty, 
when  both  sides  are  affected,  of  correctly  valuing  the  percussion  find- 
ings. He  divides  percussion  sounds  into  several  varieties,  too  elaborate 
to  be  here  reproduced,  disapproves  of  the  customary  symmetrical  com- 
parative ^percussion,  and  advises  beginning  percussion  in  regions  where 
normally  there  is  a  clear,  full  percussion  note — i.  e.,  in  front,  in  the 
infraclavicular  fossae  and  behind  in  the  region  of  the  angle  of  the 
scapula. 

Use  of  X-rays. — Valuable  papers  by  Williams,  Ivrause,  and  Kist 
w'ere  read.  The  former  stated,  in  agreement  with  his  past  attitude, 
that  "  X-ray  examinations,  while  not  infallible,  add  to  our  knowledge 
of  conditions  present  in  the  thorax,  and  give  fuller,  more  accurate,  or 
earlier  information  than  the  older  methods."  Krause  noted  that,  "  in 
the  main.  X-ray  diagnosis  merely  confirms  and  completes  the  clinical 
findings  and  is  limited  to  the  detection  of  differences  in  density  in  the 
lung,"  a  conservative  view.  He  considers  that  infiltration  which  can- 
not be  determined  by  percussion  can  often  be  demonstrated  by  the  radio- 
gram, but  that  a  simple  catarrhal  process  in  the  early  stage  cannot  be 
demonstrated  either  by  the  fluoroscope  or  by  radiography.  Later  the 
apices  appear  dark  and  do  not  clear  up  during  inspiration.  He  con- 
siders that  Williams's  sign  has  no  diagnostic  value.  He  also  dwells  on 
the  extreme  value  of  the  X-ray  in  the  diagnosis  of  bronchial-gland 
enlargements  in  children.  Rist  very  wisely  emphasized  the  importance 
of  a  thorough  familiarity  by  the  physician  making  the  X-ray  examina- 
tion, with  the  refinements  of  clinical  methods  of  diagnosis  of  tuber- 
culosis, and  noted  that  if  clinical  diagnostic  work  is  to  be  in  the  hands 
of  one  man  and  the  X-ray  work  in  the  hands  of  another,  serious  mis- 
takes are  apt  to  occur. 

Prognosis. — Casselberry  emphasizes  the  fact  that  the  prognosis  of 
laryngeal  tuberculosis  is  better  than  is  generally  supposed,  and  that 
tuberculous  hyperplasia  can  resolve  and  tuberculous  ulcers  will  occa- 


ADDENDA  387 

sioiially  heal   iu  cases   si  lowing  a  good  resistance   to  the  disease   gen- 
erally. 

Craig  studied  the  prognosis  in  children.  This  he  believes  is  best 
estimated  first  by  the  amount  of  lung  involvement,  next  by  the  pulse- 
rate,  and  last  by  the  respiration  rate.  Older  children  show  slightly  bet- 
ter results  than  younger,  and  those  treated  in  sanatoria  better  results 
than  those  treated  in  dispensaries  or  hospitals.  The  results  in  children 
if  the  disease  were  not  extensive  were  better  than  in  adults,  but  when 
it  was  advanced  thev  were  not  so  good. 


PART   IV 
PROPHYLAXIS    OF    TUBERCULOSIS 


INTRODUCTION 
By   HERMANN   M.   BIGGS 

Questions  relating  to  prophylaxis  have  come  more  and  more  to 
dominate  the  consideration  of  the  social,  economic,  and  medical  aspects 
of  the  great  problem  presented  by  the  universal  prevalence  of  tuber- 
culosis. 

While  it  is  everywhere  recognized  that  great  progress  has  been 
made  in  the  treatment  of  the  various  forms  of  this  disease  by  the  devel- 
opment of  the  hygienic,  climatic,  and  dietetic  phases  of  the  subject, 
and  while  the  earlier  recognition  of  the  pulmonary  form  of  tuberculosis 
has,  and  is  still,  very  largely  increasing  the  percentage  of  cases  of  pul- 
monary tuberculosis,  which  may  properly  be  brought  within  the  scope 
of  treatment,  and  while  bacteriological  researches  have  contributed 
much  information,  which  gives  promise  of  ultimate  vsuccess  -in  the  spe- 
cific treatment  of  tliis  disease,  yet  we  are  realizing  more  fully  each  year 
that  the  solution  of  the  prol)lem  looks  forward  to  the  development  of 
more  efficient  and  far-reaching  measures  of  governmental  control. 

It  is  the  administrative  control,  with  prophylaxis  chiefly  in  view, 
which  is  growing  most  in  importance,  and  a  very  hopeful  sign  of  the 
times  in  this  respect  is  the  increasing  acceptance  by  sanitary  authorities 
of  a  broader  conception  of  their  functions  and  duties  with  reference  to 
this  disease.  Of  course,  in  the  ultimate  analysis  the  prophylaxis  of 
tuberculosis  is  connected  with  all  those  fundamental  problems  which 
have  to  do  with  the  lives  of  the  lower  and  middle  classes  of  society; 
those  relating  to  the  hygienic  conditions  obtaining  in  their  homes  and 
workshops,  such  as  lighting.  h(>aliiig.  ventilation.  jiUimbing,  and  the 
air  space;  the  relative  width  of  the  streets  and  the  height  of  the  build- 
ings; small  parks  and  open  spaces;  the  purity  and  character  of  the  food- 
supplies;  the  regulation  of  the  hours  and  condition  of  labor,  matters 
relating  to  school  hygiene,  and  numerous  other  similar  considerations. 

The  questions  relating  to  immediate  prophylaxis  as  connected  with 
the  infection  possibly  surrounding  the  affected  individual  have  to  do 
primarily  with  his  education  and  with  the  development  of  a  sense  of 
responsibility  in  him  for  (he  adoption  of  precautionary  measures,  as 
well  as  the  growth  of  an  intelligeul  demand  on  the  part  of  the  well, 
(hai  fhey  shall  be  subjected  to  no  needless  exposure  becaus(>  of  the  care- 

391 


392  PROPHYLAXIS   OF   TUBERCULOSIS 

lessness  of  the  sick.  With  this,  too,  there  must  come  a  more  general 
recognition  of  the  duty  of  the  sanitary  authorities  to  exercise  more  strict 
police  surveillance  over  tuberculous  individuals,  and,  when  necessary 
for  the  protection  of  others,  to  insist  on  the  forcible  removal  to  insti- 
tutions of  persons  who  are  unable  or  unwilling  to  take  these  precautions 
which  are  necessary  to  render  them  free  of  danger  to  other  persons. 

It  has  come  to  be  pretty  generally  recognized  as  the  duty  of  the 
authorities  to  provide  sufficient  facilities  for  the  treatment  of  these 
patients  in  dispensaries,  hospitals,  sanatoria,  day  camps,  etc. 

As  long  as  the  problem  of  prophylaxis  is  so  intimately  associated 
Avith  the  fundamental  conditions  of  life  of  the  masses  of  the  population, 
we  cannot  hope  for  any  early  and  complete  eradication  of  this  disease, 
but  we  may  very  properly  hope  for  and  expect  that  there  shall  be  a 
fairly  regular  and  continuous  decrease  in  the  prevalence  of  tuberculosis 
in  all  well-regulated  communities.  The  time  is  not  far  distant  when 
the  lack  of  proper  measures  of  precaution  in  any  community  will  be 
regarded  as  proof  of  negligence  and  incompetence  on  the  part  of  the 
sanitary  authorities  and  gross  indifference  to  their  own  welfare  on  the 
part  of  the  general  public. 


CHAPTER   I 

IXDIVIDUAL    TROPHYLAXIS 
By   EDWARD   R.    BALDWIN 

MEASURES   FOR   THE   HEALTHY   INDIVIDUAL 

The  efficacious  prevention  of  tuberculosis  involves  the  protection  of 
the  healthy  individual  from  needless  exposure  to  the  infection,  so  far  as 
is  possible.  Since,  however,  complete  annihilation  of  infective  material 
cannot  be  contemplated  in  a  generation  or  two  at  least,  measures  to 
minimize  the  danger  by  reducing  the  amount  and  frequency  of  expo- 
sure on  the  one  hand,  and  to  increase  the  resistance  of  the  healthy 
individual  to  the  inevitable  exposure  on  the  other  hand,  must  be  de- 
pended on  at  present.  These  measures  can  hardly  be  less  important  in 
causing  the  gradual  extinction  of  tuberculosis  than  those  directed  toward 
the  control  of  the  consumptive  individual  himself,  considering  the  pres- 
ent state  of  civilization. 

The  protective  measures  must  also  be  viewed  as  to  their  importance 
in  inverse  proportion  to  the  age  of  the  individual.  Precautions  which 
are  of  the  utmost  importance  for  young  infants  become  almost  super- 
fluous for  adults,  when  we  consider  the  greater  relative  resistance  of 
the  latter  to  infection. 

Infancy. — Xontuberculous  Pabentage. — The  most  enlightened 
opinions  as  to  the  danger  of  infection  to  the  youngest  infants  justify 
every  precaution  that  can  be  taken  in  the  isolation  and  feeding  of  the 
new-l)orn,  whether  the  parents  are  apparently  free  from  tuberculosis  or 
not.  Unsuspected  tuberculosis  in  the  parents  is  very  common.  If  the 
mother  has  had  a  latent  focus,  there  is  no  time  more  propitious  for  it 
to  become  active  tlian  during  parturition  and  lactation.  Consequently, 
obscure  ailments  in  the  mother  or  wet-nurse,  especially  when  accom- 
panied by  fever  or  cough,  should  be  the  signal  to  discontinue  breast 
feeding  if  tuberculosis  cannot  be  excluded. 

Milk. — The  necessity  for  artificial  feeding  involves  infinite  care  to 
insure  against  the  danger  of  conveying  tubercle  bacilli  in  the  milk. 
The  ideal  conditions  are  to  have  the  absolute  assurance  that  tuberculin- 
tested  cows  constitute  the  only  source  of  the  milk,  and  that,  in  its 
27  '  -.m 


394  INDIVIDUAL   PROPHYLAXIS 

handling  or  transportation,  no  tuberculous  person  is  employed;  further- 
more, that  exposure  to  dust  or  insects  does  not  occur.  When  these  con- 
ditions can  be  fulfilled  no  danger  can  be  apprehended  from  the  use 
of  raw  milk,  but  in  the  complexity  of  city  life  few  can  have  these 
advantages.  Hence,  sterilization  in  some  form  becomes  the  only 
safeguard. 

Pasteurization  leads  among  all  methods  for  accomplishing  this  end. 
The  suspicion  that  milk  has  been  exposed  in  public  places  should  be 
reason  enough  to  have  it  pasteurized;  nor  should  it  be  forgotten  that 
it  may  be  contaminated  after  pasteurization  if  carelessly  exposed,  and 
that  cream  requires  the  same  precautions.  The  heating  should  be  done 
in  a  closed  vessel,  otherwise  the  surface  layer  will  not  be  sterilized.  The 
addition  of  antiseptics,  such  as  formalin  and  boric  acid,  cannot  be  jus- 
tified either  on  the  ground  of  efficiency  in  killing  the  bacillus  or  of  harm- 
lessness.  The  least  objectionable  method  is  that  of  adding  hydrogen 
peroxid  (Budde).  The  modifications  introduced  by  De  Waele,  Sugg, 
and  Vandevelde,  and  also  Much  and  Roemer  ("  perhvdrase"),  by  which 
the  HoOo  is  decomposed  by  a  blood  enzyme  after  acting  as  an  antiseptic, 
have  thus  far  had  insufficient  trial  to  prove  their  reliability. 

Tuberculous  relatives  or  other  members  of  the  household,  such  as 
nurses,  servants,  visiting  guests,  or  boarders,  should  be  prevented  from 
coming  into  close  contact  with  infants  if  these  persons  have  open  tuber- 
culosis. They  should  avoid  kissing  the  infant  and  coughing  when  near  it. 
They  should  neither  be  permitted  to  prepare  nor  taste  the  food,  nor 
offer  it  in  the  same  cups,  glasses,  or  spoons  which  they  are  themselves 
in  the  act  of  using,  as  is  so  frequently  done  among  the  poor. 

The  ever-ready  handkerchief  forms  a  dangerous  weapon  with  which 
to  wipe  the  infant's  hands  and  mouth,  and  the  custom  is  widespread 
among  otherwise  cleanly  women  of  expectorating  into  handkerchiefs. 
The  unwashed  fingers  of  relatives  too  often  find  their  way  into  the 
infant's  mouth,  or  during  the  teething  period  contaminate  its  fingers 
and  toys,  thus  indirectly  carrying  infection  obtained  elsewhere.  Like- 
wise pets,  especially  dogs,  who  are  in  the  habit  of  lying  on  the  sidewalks 
and  steps,  may  become  soiled  with  sputum  and  convey  infection  to  the 
nursery. 

Overshoes,  walMng  hoots,  and  sl-irts  should  not  be  neglected  as  pos- 
sible sources  of  danger  to  the  creeping  infant,  and  they  should  not  be 
cleaned  in  any  living  room.  It  is  of  the  greatest  importance  to  have 
the  floor  of  the  nursery  frequently  cleaned  and  covered,  if  at  all,  with 
movable  rugs  and  matting. 

Traveling  in  public  conveyances  with  infants  probably  involves  less 
danger  of  tuberculous  infection  than  is  popularly  supposed,  inasmuch 
as  the  chance  contact  is  of  short  duration.    Infants  should  not  be  seated 


MEASURES  FOR  THE  HEALTHY   INDIVIDUAL  395 

in  coaches  where"  antispitting  ordinances  are  not  enforced  and  where 
dusting  of  clothing  is  permitted,  if  such  exposure  can  be  avoided. 

Visiting  public  resorts  and  houses  where  tuberculous  persons  reside 
is  to  be  discouraged  on  general  principles,  though  the  danger  to  infants 
is  conceivably  far  less  than  from  other  diseases.  Public  halls,  waiting 
rooms,  and  amusement  places  in  general  are  likewise  to  be  avoided 
so  far  as  possible.  The  monkey  house  of  the  zoological  gardens  is  a 
place  of  danger  by  reason  of  the  frequency  of  the  disease  in  these 
animals. 

Diseases,  especially  the  exanthematous  infections,  which  give  favor- 
able times  and  places  for  the  reception  and  development  of  tuberculosis, 
should  not  be  dealt  with  lightly  by  the  laity.  Whooping  cough,  diph- 
theria, and  tonsillitis  present  all  the  favoring  conditions  for  infection 
through  the  air  passages,  while  gastroenteritis  gives  the  opportunity 
for  its  entrance  by  way  of  the  intestine.  The  gradual  extinction  of  the 
acute  infections  by  efficient  quarantine  and  sanitation  will  doubtless 
go  far  toward  decreasing  tuberculosis,  which  would  often  fail  to  develop 
when  the  infection  is  feeble  but  for  them. 

Extra  precaution  should  be  taken  with  children  known  to  have  ade- 
nitis that  they  shall  not  be  exposed  unnecessarily  to  children's  diseases, 
or  under  the  instruction  of  a  tuberculous  teacher  or  governess.  En- 
iarged  tonsils,  whether  faucial  or  pharyngeal,  are  a  menace  of  tuber- 
culous infection  either  actual  or  potential,  and  removal  is  indicated  in 
nearly  all  cases.  It  is  highly  probable  that  the  gateway  of  infection  is 
thereby  sealed  in  many  cases  by  timely  operation.  In  any  case,  mouth- 
breathing  is  to  be  remedied  if  it  has  resulted  from  these  causes.  Carious 
teeth  should  be  removed  and  the  gums  protected  from  ulceration. 

Digestive  disturhances  are  frequently  caused  by  careless  feeding  of 
children.  They  should  be  restricted  as  to  sweets,  and  taught  to  avoid 
unripe  fruit  and  gluttony.  The  presence  of  intestinal  catarrh  or  gas- 
tric dyspepsia  paves  the  way  for  infection  otherwise  unlikely  to  gain  a 
foothold. 

Accidents. — Falls  on  the  head,  blows,  or  concussion  of  any  kind 
should  be  guarded  against,  for  the  popidar  idea  of  their  connection 
with  a  subsequent  meningeal  joint  or  bone  tuberculosis  has  considerable 
foundation  in  clinical  experience. 

Inoculation  tuberculosis  from  scratches  is  sufficiently  common  to 
require  care  in  covering  eczematous  patches  on  the  skin  of  infants,  and 
to  observe  scrupulous  cleanliness  with  their  hands  and  toys  during  the 
period  of  teething.  The  possibility  of  conveying  tubercle  bacilli  by 
means  of  insects  should  be  guarded  against  by  screening  sleeping  in- 
fants. Vaccination  has  no  longer  any  reason  to  be  charged  with  the 
inoculation  of  tuberculosis  where  calf  virus  is  used.     Only  the  grossest 


396  INDIVIDUAL    PROPHYLAXIS 

carelessness  and  neglect  could  produce  such  a  result.  The  same  may 
be  said  of  circumcision. 

Tuberculous  Parentage. — \Mien  one  or  both  parents  have  tuber- 
culosis, there  are  numerous  precautions  to  be  taken  if  complete  isolation 
of  the  infant  is  not  feasible. 

Isolation:  ^Vhen  NeceKmry. — Even  with  the  most  minute  attention 
to  details,  the  presence  of  open  tuberculosis  in  a  mother  almost  inevi- 
tably involves  some  danger  of  infection  to  her  infant  when  it  is  under 
her  care.  The  tuberculous  father  can  readily  avoid  close  contact  with 
his  child ;  not  so  the  mother,  who,  though  she  may  not  nurse  the  babe, 
must  pi-epare  its  food  and  attend  to  its  wants  because  there  is  no  other 
person  to  do  it.  Complete  isolation  is,  therefore,  logically  the  ideal 
for  the  infant  with  a  tuberculous  mother  who  is  expectorating  bacilli. 
If  the  disease  is  latent  or  already  healed,  there  can  be  no  danger  for  the 
infant,  though  the  wisdom  of  breast  feeding  by  the  mother  for  her  own 
and  the  infant's  interest  must  be  a  question  in  every  case. 

The  possibility  of  obtaining  the  infection  directly  from  the  milk  is 
very  remote  even  where  active  tuberculosis  exists,  unless  the  mammary 
gland  is  involved,  but  the  nipples  are  readily  soiled  by  the  mother's 
fingers  under  these  conditions,  and  may  thus  indirectly  convey  the 
bacilli.  Besides  the  conveyance  of  infection  in  the  milk,  the  possibility 
of  transmission  of  a  specific  susceptibility  to  the  disease  is  to  be  re- 
garded, though  actual  proof  of  this  is  not  easily  obtained.  Where  the 
tuberculous  parents  must  of  necessity  associate  closely  with  the  infant, 
the  danger  can  be  reduced  to  a  minimum  by  avoidance  of  coughing  in 
the  immediate  vicinity  of  the  infant,  carefully  shielding  the  mouth  dur- 
ing the  act,  and  by  careful  attention  to  all  the  other  details  of  personal 
hygiene  elsewhere  mentioned  for  tuberculous  individuals. 

Special  measures  directed  toward  increasing  the  resistance  of  the 
infant  are  of  the  utmost  value,  and  the  most  important  is  care  in  feed- 
ing. Proper  modification  of  cow's  milk,  suited  to  the  age  and  capacity 
of  the  nursling,  as  well  as  regularity  in  feeding,  should  be  secured.  In 
this  way  frequent  gastrointestinal  catarrhs  may  be  avoided  which  doubt- 
less favor  the  lodgment  of  tubercle  bacilli,  when  otherwise  they  would 
not  gain  entrance.  Constipation  is  only  second  in  importance  in  favor- 
ing infection  and  must  be  combated  with  mild  measures. 

Immunized  Milk. — The  possibility  of  conveying  antibodies  from 
immunized  cow's  milk  which  shall  avail  to  increase  the  resistance  of 
infants  has  received  some  experimental  support.  Figari,  v.  Behring, 
Eoemer,  and  Much  have  demonstrated  increased  agglutinative  power 
for  tubercle  bacilli  in  such  milk  and  its  transference  to  offspring.  The 
activity  of  this  and  other  hypothetic  antagonistic  substances,  neverthe- 
less, appears  to  be  rather  restricted,  since  it  has  been  found  (Eoemer) 


MEASURES  FOR   THE   HEALTHY   INDIMDUAL  397 

that  only  during  the  first  eight  days  after  birth  are  proteid  substances 
absorbed  unchanged  by  digestive  action.  The  advantage  resulting  from 
the  employment  of  such  milk  for  infants  is  largely  theoretic  at  present. 
But  little  application  has  been  made  of  the  principle,  and  it  is  prema- 
ture to  venture  an  opinion  of  its  possibilities. 

Active  immunization  of  infants  by  means  of  feeding  tubercle  bacilli 
or  their  products,  made  innocuous  in  various  ways,  has  a  promise  of  appli- 
cation in  the  future  since  success  has  been  obtained  with  suckling  calves 
and  guinea  pigs,  in  the  experiments  of  Calmette,  Guerin,  and  Morin. 

General  Hygiene,  Climate,  etc. — Much  can  be  done  by  intelligent 
care  to  strengthen  infants  against  infection  by  keeping  them  out  of 
doors  in  all  weather  except  the  most  severe  heat  and  cold.  The  morning 
nap  may  profitably  be  taken  on  a  sheltered  veranda  in  cool  weather, 
where  safety  and  quiet  can  be  assured,  or  in  a  cold  room  if  this  is  not 
available.  Catarrhal  colds  may  be  warded  off  by  cool  sponging  and 
friction  to  the  neck  and  chest,  suiting  the  temperature  to  the  growth 
and  daily  condition  of  the  infant.  Favorable  climatic  conditions,  if 
possible,  should  be  secured  for  the  offspring  of  tuberculous  parents. 
Those  who  are  congenitally  delicate  and  persistently  under-nourished 
thrive  best  in  Southern  California  or  the  southern  Atlantic  States  in 
winter,  especially  among  the  pines  and  on  the  coast.  Infants  with  nor- 
mal assimilative  powers  are  better  in  the  highlands  of  Colorado,  Xorth 
Carolina,  or  the  Adirondacks,  both  winter  and  summer. 

Childhood. — The  same  recommendations  can  be  made  with  more 
insistence  for  children  over  two  years  of  age,  because  the  opportunity 
for  outdoor  life  is  greater  with  increasing  age  and  invigorating  meas- 
ures are  more  effective. 

Food. — With  the  weaning  of  a  breast-fed  infant  begins  whatever 
opportunity  for  food  infection  there  may  be  from  other  sources.  So 
far  as  evidence  has  been  adduced,  there  is  little  danger  outside  of  milk 
and  its  products,  butter  and  cheese.  The  contamination  of  food  is, 
however,  easier  with  the  greater  freedom  of  movement  enjoyed  by  the 
child.  Bread,  cakes,  fruit,  and  confectionery  are  occasionally  handled 
by  tuberculous  persons  at  the  shops,  and  often  soiled  by  dirty  hands. 
The  child  plays  on  the  floor  or  sidewalk,  handles  door  knobs  and  latches, 
public  cups,  and  innumerable  other  things  used  in  common  which  may 
convey  infection.  Fortunately  these  sources  do  not  constitute  a  great 
danger  in  nontuberculous  families.  Attention  to  cleanliness  is  the 
prime  factor  of  safety  here  as  in  all  else  that  concerns  prophylaxis. 
The  food  should  be  abundant  and  especially  rich  in  fats  and  proteids 
for  children  of  tuljerculous  parentage.  The  butter-  and  cream-eating 
habit  should  be  encouraged  in  such  children.  A  liking  for  cod-liver 
oil  is  not  infrequently  acquired  by  children  with  advantage. 


398  INDIVIDUAL   PROPHYLAXIS 

Clothing. — When  children  are  congenitally  malnourished,  it  must  not 
be  thought  that  their  clothing  is  an  indifferent  matter.  They  require 
more  underclothing  than  the  better-nourished  children,  preferably  wool 
next  the  skin  in  winter,  and  especial  care  to  prevent  wetting  the  feet. 
Bare  legs  and  arms  in  cold  weather  are  certainly  irrational  measures 
for  the  purpose  of  hardening  most  children,  however  successful  with 
some.  Head  covering  in  hot  sunshine  should  always  be  provided  for 
children.  The  neck  and  chest  should  not  be  confined  tightly  nor  bun- 
dled warmly  except  in  coldest  weather. 

Bathing  and  Exercise. — A  morning  sponge  with  cool  water  and  a 
warm  tub  bath  twice  a  week  at  night,  merit  constant  attention  for  deli- 
cate children ;  the  habit  is  then  formed  early  and  increased  resistance 
to  changes  of  temperature  is  acquired. 

The  question  of  sea-  or  fresh-water  bathing  in  the  open  is  an  impor- 
tant one  for  the  physician  to  decide  for  each  individual.  No  rules  can 
be  laid  down  except  the  general  ones  that  the  time  spent  in  the  water 
should  never  be  long  enough  to  produce  cyanosis  and  pronounced  chilli- 
ness, and  also  the  warning  against  entering  the  water  when  overheated 
or  directly  after  meals.  Injury  has  often  resulted  from  neglect  by  par- 
ents and  physicians  in  this  matter,  by  which  the  foundation  for  a  future 
pulmonary  tuberculosis  is  laid. 

Exhaustion  from  overrunning  and  excessive  play  is  a  frequent 
source  of  illness  and  debility  in  delicate  children,  especially  those  of 
active  mentality,  not  unusual  among  children  of  tuberculous  parentage. 
Violent  games  should  be  discouraged  for  any  child  suspected  of  latent 
lymphatic,  bone,  or  joint  tuberculosis.  On  the  other  hand,  calisthenics 
and  the  respiratory  exercises  recommended  by  Knopf  are  very  important 
in  developing  weakly  children. 

Sleep. — Children  under  fifteen  years  of  age  require  from  ten  to  twelve 
hours  sleep  daily.  Some  are  benefited  by  an  after-luncheon  nap,  but 
this  leads  to  the  temptation  to  keep  a  wide-awake  child  up  later  in  the 
evening.  Delicate  children  must  be  prevented  from  frequent  attendance 
at  evening  parties.  Unless  suffering  from  recent  colds  or  diseases,  chil- 
dren should  sleep  in  cool  rooms,  with  at  least  one  window  open.  Night 
clothing  of  flannel,  with  foot  covering,  is  desirable  for  cold  weather. 

Habits. — No  time  can  be  better  spent  for  the  prevention  of  tuber- 
culosis than  in  teaching  cleanly  habits  to  young  children.  It  should 
be  the  constant  aim  of  parents  and  teachers  to  keep  the  hands  and  nails 
of  children  clean,  to  prevent  picking  of  the  nose  and  scratching  of 
abraded  surfaces,  herpetic  or  eczematous  patehes,  etc.,  which  may  thus 
1)6  the  source  of  inoculation  tuberculosis.  The  sanitary  instruction  now 
being  introduced  into  public  schools  promises  much  in  the  furtherance 
of  prevention. 


MEASURES   FOR  THE   HEALTHY  INDIVIDUAL  399 

The  follo'wiiig  brief  presentation  of  simple  health  rules  was  made  by 
the  Hawthorne  Club,  a  group  of  tenement-house  children  in  Boston : 

HEALTH    RULES    FOR    SCHOOL    CHILDREN 

1.  Health  is  wealth. 

2.  Do  not  put  pins  in  your  mouth. 

3.  Do  not  hold  money  in  your  mouth. 

4.  Do  not  put  your  fingers  in  your  mouth. 

5.  Do  not  put  pencils  in  your  mouth  or  wet  them  with  your  lips. 

6.  Do  not  wet  your  finger  in  your  mouth  when  turning  the  leaves 
of  books. 

7.  Do  not  put  anything  into  your  mouth  except  food  and  drink. 

8.  Never  spit  on  your  slate  or  on  the  floor  or  sidewalk. 

9.  Do  not  pick  your  nose  or  wipe  it  with  your  hand  or  sleeve. 

10.  Keep  your  face,  hands,  and  finger  nails  clean. 

11.  Keep  the  interior  of  your  body  clean  by  allowing  nothing  to  go  into 
it  excepting  pure  food  and  pure  drink. 

12.  Do  not  keep  your  rubbers  on  in  the  schoolroom. 

13.  Do  not  sit  with  wet  feet  or  damp  clothing;  resort  to  the  stove  or 
register  until  they  are  dry. 

14.  Do  not  swap  parts  of  apples,  candy,  chewing  gum,  half-eaten  food, 
whistles,  or  anything  that  is  to  be  put  in  the  mouth. 

15.  Xever  cough  or  sneeze  in  a  person's  face.  Turn  your  face  to  one 
side  and  hold  a  handkerchief  before  your  mouth. 

16.  When  drinking,  rinse  out  the  cup,  and  empty  what  water  you  leave 
into  the  wash  basin  or  sink. 

17.  Breathe  only  fresh  air  day  and  night ;  simply  avoid  draughts. 

18.  Breathe,  sit,  stand,  and  walk  correctly.  In  so  doing  you  will  do 
more  to  prevent  consumption  than  all  the  physicians  combined.  A  good 
pair  of  lungs  is  the  most  efficacious  barrier  to  this  disease. 

19.  Go  to  bed  early,  rise  early,  and  take  plenty  of  "  physical  culture," 
helping  father  and  mother,  before  and  after  school,  with  the  "  chores." 

20.  Study  the  physiology — to  know  how  to  use  rightly  and  take  proper 
care  of  every  part  of  the  body. 

Schooling. — The  amount  of  strain  which  schooling  brings  to  a  child 
must  be  considered  carefully,  particularly  with  children  of  tuberculous 
parentage,  whether  they  are  already  infected  or  not.  Apart  from  the 
danger  of  infectious  diseases  likely  to  be  acquired  at  school — especially 
measles,  whooping  cough,  scarlet  fever,  and  diphtheria — the  well-known 
precocity  and  intellectual  keenness  of  many  such  children  is  a  reason  for 
restraint  rather  than  stimulus  in  study,  and  the  family  physician  may 
properly  err  on  the  side  of  overwillingness  to  grant  certificates  asking 
for  shorter  hours  and  absences  to  these  children.  Work  at  home  or 
elsewhere,  when  it  restricts  outdoor  life  and  the  normal  development, 
should  be  abolished  by  law. 


400  INDIVIDUAL   PROPHYLAXIS 

An  excellent  scheme  for  keeping  children  out  of  doors  in  cities  is 
the  roof  garden  devised  and  successfully  used  by  Dr.  Northrup  in  New 
York  (see  Fig.  122). 

Youth. — Period  of  Puberty. — With  the  advent  of  sexual  conscious- 
ness, a  period  of  danger  arrives  in  relation  to  tuberculosis.  It  is  chiefly 
with  those  children  who  have  already  become  infected  that  the  fear  of 
an  outbreak  should  be  greatest,  for  the  actual  danger  of  primary  infec- 
tion is  probably  less  during  the  years  of  adolescence  when  active  outdoor 
life  is  the  rule.  Rapid  growth  and  instability  of  the  nervous  system 
tend  to  favor  the  spread  of  latent  disease,  and  the  suspicion  of  any  focus 
of  this  kind  should  lead  to  constant  watchfulness.  Periodic  examina- 
tions by  the  physician  are  strongly  to  be  recommended,  and  much  de- 
pends on  his  care  and  tact  with  delicate  youths.  Avoidance  of  mastur- 
bation can  be  taught  best  by  the  family  physician,  and  its  debasing 
moral  and  physical  effects  j)resented  in  a  judicious  way,  supplementing 
the  generally  desultory  efforts  of  parents  and  teachers.  Signs  of  chlo- 
rosis or  markedly  irregular  menstruation  in  girls  call  for  increased 
vigilance  in  reference  to  latent  tuberculosis. 

Overstrain  has  been  the  bane  of  modern  life  for  adolescents.  Ex- 
hausting wheeling  trips  and  racing  of  all  kinds  are  common.  Athletic 
contests  and  overtraining  are  associated  Avith  the  development  of  tuber- 
culosis with  sufficient  frequence,  even  in  the  robust,  to  justify  constant 
restraint.  The  presence  of  latent  tuberculosis  has  often  been  unsus- 
pected by  physical  directors,  and  more  care  is  required  in  obtaining  the 
previous  histories  of  candidates  for  college  teams.  Mental  and  nervous 
strain  is  to  be  prevented  quite  as  much  as  physical  overexertion,  for 
the  latter  naturally  concerns  the  strong,  while  overstudy  and  nervous 
excitement  oftener  affect  the  less  vigorous.  Late  and  irregular  hours, 
insufficient  sleep,  excessive  smoking,  eating,  and  drinking,  combine  to 
undermine  the  resistance  of  many  college  youths  who  have  inherited 
or  acquired  susceptibility  to  the  disease. 

Moral  training  is  especially  important  for  venereal  prophylaxis,  and 
has  been  sadly  wanting  in  the  past.  Fortunately,  educators  and  publi- 
cists are  now  endeavoring  to  supplement  the  efforts  of  physicians  in  this 
direction,  and  a  potent  factor  at  the  root  of  much  tuberculosis  is  being 
grappled  with.  Nevertheless,  the  most  effective  work  is  that  which 
may  be  done  by  the  personal  influence  of  the  physician. 

Adult. — Promotion  of  Good  Physique. — When  full  growth  is  at- 
tained and  the  life  work  entered  on,  individuals  with  delicate  constitu- 
tions are  the  first  to  contribute  to  the  harvest  of  tuberculosis,  which  is 
always  greatest  at  the  threshold  of  married,  business,  and  professional 
life.  The  open-air  life  of  youth  is  abandoned,  and  responsibilities  accu- 
mulate which  tend  to  lower  resistance  by  their  demands  on  the  physical 


MEASURES   FOR  THE   HEALTHY    INDIVIDUAL 


401 


aud  mental  powers.  Xor  can  it  be  forgotten  that  the  strongest  some- 
times succumb.  Xone  can  be  excluded  in  the  application  of  rules  of 
hygiene.  Good  muscular  vigor  should  be  furthered  b}'  walking,  deep 
breathing,  and  open-air  sports  generally.  Golf  is  one  of  the  foremost 
useful  games  for  sedentary  persons,  while  driving  and  boating  are 
especially  good  for  those  more  actively  employed  and  required  to  stand 


Fig.  122. — Playground  on  Roof  of  Residence  in  New  York  City. 
(Dr.  Northrup). 


much  on  their  feet.  It  is  often  important  that  otherwise  desirable  indoor 
recreation  be  replaced  by  outdoor  work,  such  as  gardening.  On  the 
other  hand,  mental  recreation  is  highly  important  to  maintain  vigorous 
intellectual  power  and,  indirectly,  a  stable  nervous  system,  so  often  lack- 
ing in  persons  predisposed  to  tuberculosis. 

Habits. — Regularity  and  temperance  in  all  things  are  requisite  for 
the  maintenance  of  good  resistance  in  the  strong,  and  doubly  so  in 


402 


INDIVIDUAL   PROPHYLAXIS 


persons  predisposed  to  tuberculosis.  Even  moderate  dissipation  may 
arouse  a  latent  infection  into  activity,  so  that  alcohol,  tobacco,  and  late 
suppers  can  be  dispensed  with  by  such  individuals.  Temporary  exhaus- 
tion from  excesses  of  any  kind  is  readily  forgotten  until  a  breakdown 
occurs,  so  that  constant  warnings  are  needed.  Carefulness  in  dress  so 
as  to  avoid  chilling  and  wetting,  in  diet  and  eating  that  the  necessary 
time  is  taken  for  proper  mastication,  and  in  sleeping  that  fresh  air  is 
obtained,  should  be  insisted  on  specifically  and  often  by  the  family  phy- 
sician; otherwise  gradual  neglect  of  simple  hygiene  commonly  prevails 
in  most  families. 

Occupation. — In  the  choice  of  an  occupation  everyone  should  have 
the  advice  of  a  physician  familiar  with  the  physique  of  the  family,  if 


Fig.  123. — Sleeping  Balcony.     (Private  house,  Saranac  Lake,  N.  Y.) 


possible.  Too  often  necessity  drives  ill-nourished,  thin-chested  indi- 
viduals, and  those  who  are  physically  under-developed,  into  an  indoor 
trade  or  behind  the  counter.  Practically  all  the  "  light "  occupations 
are  indoors,  so  that  the  problem  is  not  what  occupation  to  select  which 
will  give  the  individual  an  outdoor  life,  liut  how  one  can  be  adjusted 
to  it  so  as  to  get  the  most  time  in  the  open  air  and  have  healthful  work- 
ing conditions  indoors.  Dusty  employment  should  not  be  permitted  for 
persons  predisposed  or  those  already  the  victims  of  latent  tuberculosis, 
nor  should  trades  that  involve  exposure  to  wetting,  steam,  vapor,  and 


MEASURES  FOR  THE   HEALTHY   INDIVIDUAL 


403 


extremes  of  temperature,  like  confectioners,  bakers,  and  plumbers,  be 
selected  by  any  person  who  may  be  predisposed  to  tuberculosis.  Clerical 
and  professional  pursuits,  involving  as  they  often  do  great  mental  strain, 
ought  not  to  be  undertaken  by  very  excitable,  nervously  constituted 
individuals.  Where  possible,  such  persons  should  be  guided  into  agri- 
cultural or  allied  occupations.  The  transportation,  mail,  and  express 
services  offer  many  desirable  places  for  open-air  employment. 

Dwellings. — Modern  urban  life  is  inexorable  in  its  crowding,  with 
consequent  restricted  light  and  air.  It  should  be  the  aim  of  families 
which  have  had  tuberculosis  among  their  members,  or  which,  for  any 
reason,  are  predisposed,  to  secure  a  suburban  house  isolated  from  others 
so  that  all  sides  may  receive  light  and  air.  No  unlighted  hallways, 
basement  rooms,  or  damp  cellars  should  be  permitted.  Houses  in 
swampy  regions  should  be  abandoned  for  higher  and  drier  locations. 
Heating  furnaces  or  radiators  should  be  furnished  with  water  evapo- 
ration tanks  to  prevent  undue  dryness.  Dry  sweeping  should  be  for- 
bidden. Living  rooms  in  winter  should  not  be  warmer  than  68°  F., 
and  the  windows  should  frequently  be  opened  at  the  top.  A  sleeping 
room  with  balcony  or  with  provision  for  a  bed  practically  out  of  doors 
is  very  desirable  for  any  family,  but  especially  for  the  one  with  a  deli- 
cate member  who  is  predisposed  to  pulmonary  disease.  Much  attention 
should  be  given  to  a  spacious  veranda  to  make  it  available  for  both 
summer  and  winter  as  a  place  for  rest  and  comfort  (see  Fig.  123). 

Houses  with  sleeping  porches  entering  into  the  building  plan  are 
being  constructed  more  and  more.  They  are  worthy  of  imitation.  The 
two  adjoining  plans  may  be  more  suggestive  (see  Figs.  124  to  127). 


rresr  flooe  plan 


sax»n  FLOoe  plan 


Figs.  124  and  125. — Cottage  Showing  Arrangement  for  One  Sleeping  Porch. 
(First  and  second  floor  plans.)  (Scopes  &  Feustmann,  architects,  Saranac 
Lake,  N.  Y.) 


Marriage. — The  question  of  nuirriage,  in  relation  to  the  danger  of 
tuberculosis,  is   not  often   first  referred   to   the  physician,   yet   serious 


404 


INDIVIDUAL    PROPHYLAXIS 


danger  might  be  averted  in  some  cases  by  his  wise  counsel.  The  things 
most  important  to  consider  for  the  husband  are  his  physical  ability  to 
bear  the  strain  of  supporting  a  wife  and  children  by  his  own  efforts, 


m    K 


I,    I   I    ,1 


BEDROOM 


•I&  PORCH 


FIRST   TUoaH  PLAN 


SECOND  TL002.  PLAN 


Figs.  126  and  127. — Cottage  Showing  Arrangement  for  Two  Sleeping  Porches. 
(First  and  second  floor  plans.)     (W.  E.  Scopes,  Architect,  Saranac  Lake,  N.  Y.) 

if  that  is  to  be  required  of  him  by  necessity  or  choice.  If  he  is  deli- 
cately organized,  and  has  a  struggle  before  him,  there  is  a  real  danger 
that  tuberculosis  may  claim  him,  yet  if  life  is  comparatively  easy,  and 
the  wife  strong,  the  union  may  be  free  from  serious  objection.  The 
children  may  also  acquire  excellent  constitutions  in  spite  of  the  paternal 
weakness,  unless  syphilis  or  some  other  taint  is  added.  On  the  other 
hand,  a  delicate  woman  must  undergo  grave  danger  of  tuberculosis  from 
child-bearing  if  latent  disease  is  present  or  the  conditions  of  life  in- 
volve exposure  to  it.  Each  case  must  be  decided  on  its  individual  indi- 
cations and  contraindications,  consideration  being  given  to  the  tem- 
peraments, social  status,  and  prospect  of  greater  or  lesser  hardships 
in  the  married  state. 


MEASURES  FOR   TUBERCULOUS   INDIVIDUALS 

Closed  Tuberculosis. — Numerous  cases  of  closed  (latent  or  healed) 
tuberculosis  have  come  to  light  in  recent  years  owing  to  the  greater 
attention  given  to  early  diagnosis  and  the  use  of  newer  diagnostic  aids, 
especially  tuberculin.  Many  tuberculous  families  are  now  being  system- 
atically examined,  and  luedical  inspection  of  school  children,  combined 
with  special  tuberculosis  dispensaries,  promise  to  reveal  an  enormous 
number  of  infected  individuals.    Adequate  public  and  private  preventive 


MEASURES  FOR  TUBERCULOUS  INDIVIDUALS  405 

agencies  will  not  fail  in  the  future  to  take  more  and  more  note  of  latent 
tuberculosis.  All  that  has  been  mentioned  in  the  preceding  pages  on 
prophylaxis  applies  especially  to  these  dormant  tuberculoses  which  may 
often  be  prevented  from  spreading  further  by  good  care. 

Scrofulosis. — Every  effort  should  be  made  to  prevent  suppuration 
and  ulceration  of  scrofulous  glands.  Bone  and  Joint  abscesses  under 
modern  surgical  treatment  can  often  be  prevented  from  rupture  and 
secondary  infection.  If  rupture  occurs  and  drainage  becomes  necessary, 
it  must  be  kept  in  mind  that  the  pus  contains  tubercle  bacilli  and  that 
the  discharges  from  the  sinuses  must  not  be  neglected  simply  because 
it  is  not  easy  to  discover  the  bacilli  in  them. 

Closed  Pulmonary  Tuberculosis. — This  may  so  readily  become  open, 
witliout  warning  symptoms,  tliat  it  is  wiser  to  provide  for  this  con- 
tingency by  observing  the  rules  for  the  care  of  the  cough  and  ex- 
pectoration, if  present.  If  these  precautions  were  more  generally 
carried  out,  "  locking  the  door  "  after  the  harm  is  done  would  be  less 
common. 

Open  Tuberculosis. — Care  of  the  Sputum. — There  is  no  doubt 
about  the  advantages  of  asepsis  over  antisepsis  in  dealing  with  tuber- 
culous sputum.  Eeliance  on  disinfectants  begets  uncleanliness  in 
handling  cuspidors  or  other  receptacles.  Hence,  with  the  most  efficient 
germicides  less  is  accomplished  than  with  a  liberal  use  of  soap  and 
water  and  the  destruction  of  expectoration  by  fire  or  boiling  heat. 
Moreover,  most  of  the  useful  disinfectants  have  a  disagreeable  odor, 
coagulate  the  sputum,  and  injure  the  skin,  besides  being  poisonous. 

Ilandkerdiiefs. — The  use  of  washable  handkerchiefs  should  be 
strictly  forbidden,  and  cloth,  gauze,  or  paper  handkerchiefs  substituted 
for  all  purposes.  The  repeated  use  of  the  same  handkerchief  or  cloth 
for  sputum  is  absolutely  unhygienic,  in  that  the  hands  will  be  unavoid- 
ably soiled  and  flakes  of  dried  mucus  are  soon  formed  and  scattered 
from  the  cloth.  If  handkerchiefs  have  of  necessity  been  used,  they 
should  be  burned  or  soaked  in  boiling  soapsuds  or  some  alkaline  dis- 
infectant, such  as  a  two-per-cent  chlorinated  lime  solution  or  a  two-per- 
cent lysol  solution  before  being  laundered.  The  ordinary  soiled  clothes 
bag  is  not  a  sanitary  place  for  any  handkerchiefs.  A  l)etter  plan  is  to 
collect  all  handkerchiefs  in  a  covered  slop  jar  during  the  week  and  pour 
boiling  suds  on  them  before  removal  to  the  laundry.  Cloth  or  bandage 
rolls  for  receiving  the  sputum  are  objectionable  because  the  fingers 
become  soiled  in  rolling  them.  Pieces  of  gauze  and  paper  handker- 
chiefs should  also  l)e  folded  several  thicknesses  for  the  same  reason. 
Paper  bags  are  the  most  satisfactory  receptacles  for  sputum  cloths. 
Rubber  pocket  linings  are  less  available  and  require  cleansing,  whereas 
the  baffs  are  to  be  burned. 


40G  INDIVIDUAL   PROPHYLAXIS 

Cuspidors. — Those  made  of  paper  are  now  in  general  use,  and  are 
preferable  to  metal  or  glass  ones  because  no  cleansing  is  required.  This 
consideration  applies  to  all  forms  of  cuspidors,  whether  for  the  pocket 
or  stand.  There  are,  however,  several  excellent  metal  and  glass  pocket 
cuspidors,  such  as  Knopf's,  Kny-Scherer's,  and  Dettweiler's,  which  can  be 
tilled  partly  with  a  disinfectant  when  in  use.  Floor  and  wall  cuspidors 
should  he  abolished  as  fast  as  the  pocket  receptacles  can  be  introduced 
to  take  their  places.  Portable  cuspidors  in  great  variety  are  to  be  had 
which  are  quite  sanitary.  Only  such  should  be  permitted  as  have  a 
cover,  so  as  to  prevent  the  access  of  flies.  Paper  cups  should  be  placed 
in  frames  of  sufficient  weight  to  prevent  their  capsizing  or  being  blown 
about  by  wind.  Cuspidors  of  agate  ware  or  china  should  be  cleansed 
with  strongly  alkaline  soap  and  hot  water,  the  sputum  having  been 
burned,  or  after  disinfection  poured  into  a  water  closet  (see  illustrations 
in  Appendix,  pages  832-839). 

Disinfection. — It  should  be  a  constant  aim  to  burn  all  sputum  where 
possible.  Admixture  with  sawdust,  paper,  and  cloth  greatly  facilitates 
the  burning,  but  care  should  be  taken  that  the  fire  is  sufficiently  strong 
to  completely  destroy  everything.  Boiling  is  also  efficient,  but  not  ordi- 
narily feasible,  outside  of  institutions.  The  alkaline  disinfectants  are 
the  best,  but  have  an  objectionable  odor  in  most  cases.  A  two-per-cent 
solution  of  chlorinated  soda  and  lime  is  most  economical  but  more 
volatile  than  lysol  (3  per  cent).  Caustic  soda  (10  per  cent)  is  satis- 
factory for  public  cuspidors,  but  requires  careful  handling  to  avoid 
injury  to  floors,  etc.  Mercuric  chlorid  (0.1  per  cent),  phenol  (5  per 
cent),  and  formalin  (3  per  cent)  are  coagulants  which  act  too  slowly 
for  most  purposes,  but  may  be  useful  where  sputum  has  been  accident- 
ally spilled  on  a  carpet  or  floor.  Cuspidors  require  more  careful  wash- 
ing when  these  have  been  used.  Fornuilin  fumigation  should  be  relied 
on  for  the  disinfection  of  garments,  rugs,  and  other  nonwashaljle  objects. 
Where  a  public  fumigatory  is  not  available,  a  closet  or  room  can  be 
utilized  and  the  formaldehyde  generated  by  the  fireless  method.^ 

Cough  Discipline. — A  well-trained  and  conscientious  consumptive 
can  do  much   to   minimize   the  danger   from   accidentallv   coughed-out 


'  For  each  1,000  cubic  feet  of  space  disinfected  take  3  ounces  of  commer- 
cial sulphuric  acid,  add  it  to  1  pint  of  water  and  pour  into  18  ounces  of  com- 
mercial formalin  in  a  vessel  of  crockery  or  agate  ware.  This  warm  mixture  is  then 
poured  quickly  on  IJ  pounds  of  fresh  unslaked  lime,  broken  into  small  lumps  in  an 
agate  or  iron  kettle,  and  placed  on  the  floor  protected  by  papers.  The  formalde- 
hyde vapor  is  rapidly  generated  so  that  it  is  necessary  to  close  the  door  at  once, 
all  openings  having  previously  been  pasted  over  with  paper.  The  door  is  then  sealed 
for  twelve  hours,  after  which  the  room  may  be  opened  and  the  contents  removed  for 
airing  and  cleaning. 


MEASURES  FOR  TUBERCULOUS   INDIVIDUALS  407 

spntuni  .spray  hy  repressing  the  cough  and  covering  the  mouth  when 
coughing.  This  can  be  cultivated  to  a  marked  degree  by  resisting  the 
tendency  until  the  sputum  can  be  raised  without  effort.  Fraenkel's 
mask  was  introduced  for  the  purpose  of  arresting  the  cough  spray,  but 
it  has  found  but  little  favor.  Simpler  measures  are  the  only  ones  likely 
to  be  carried  out  in  practice,  and  the  habit  of  covering  the  mouth  with 
cloth  is  readily  acquired.  Hawking  and  sneezing  should  be  suppressed 
if  possible,  and  the  mouth  and  nose  especially  covered  during  these 
acts.  The  head  should  always  be  turned  away  during  the  act  of  cough- 
ing and  raising  in  the  presence  of  other  persons.  It  is  surprising  how 
many  persons  forget  hygienic  breeding,  or  lack  alertness  in  practice ! 
The  patient  should  endeavor,  as  far  as  possible,  to  do  his  coughing 
in  his  own  room  or  out  of  doors,  repressing  it  elsewhere. 

Personal  Cleanliness. — The  whole  law  and  gospel  of  properly  trained 
tuberculous  patients  are  contained  in  the  expression  "  Be  ye  clean." 
This  is  of  paramount  importance  and  needs  intelligence  to  be  carried 
out  consistently.  Patients  who  gargle  and  wash  their  mouths  carefully, 
yet  swallow  their  sputum  consciously  or  unconsciously,  are  endangering 
the  intestinal  tract.  Likewise,  those  who  brush  their  teeth  carefully, 
but  wear  drooping  mustaches  or  a  beard  often  smeared  with  sputum, 
are  not  fulfilling  the  law. 

Effective  cleanliness  begins  with  mouth-washing  ^  and  gargling  after 
the  morning  cough  has  dislodged  and  raised  the  sputum.  Nothing 
should  be  swallowed  until  this  has  been  accomplished  to  as  great  a 
degree  as  possible.  The  teeth  are  then  to  be  brushed  and  a  nasal  spray 
or  douche  used  if  much  catarrh  is  present.  An  alkaline  cleansing  spray 
is  also  desirable  for  a  catarrhal  larynx  and  important  when  this  is 
tuberculous.  These  procedures  prevent  to  some  degree  autoinfection  or 
reinfection  of  the  ears,  nose,  larynx,  and  intestine,  while  frequent  and 
plentiful  use  of  soap  and  water  for  the  hands  and  face  avoids  much 
chance  of  conveying  infection  to  others. 

Mustaches  and  Ijeards  are  difficult  to  maintain  in  a  state  of  sanitary 

>  Mouth  Wash. 

I^  Olei  gaultherise vr\^  xxxvj  2.3  gm. 

Olei  eucalypti xxi  xxx  2  " 

Mentholi gr.  xx  1.3  " 

Thymoli 5  j  4  " 

Acidi  benzoici 3  iv  16  " 

Acidi  borici 5  j  30  " 

Sodii  bicarb 5  j  30  " 

Extr.  baptisiae  tinctorise f  3  iij  12  " 

Alcohol O  iij  720  " 

Aquie O  v  1200  " 

M.  With  eqviai  parts  of  water.     S.  Use  as  mouth  wash. 


408  INDIVIDUAL   PROPHYLAXIS 

cleanliness  unless  closely  trimmed,  and  should  be  shaven  when  the 
expectoration  is  profuse.  Patients  should  be  cautioned  against  hand- 
ling articles  used  by  children,  leaving  cloths  or  handkerchiefs  in  books, 
overcoat  pockets,  bureau  drawers,  and  closets,  and  also  against  permit- 
ting glasses,  spoons,  pipes,  cigar  butts,  and  toothpicks  to  lie  about  and 
get  dry.  However  insignificant  taken  singly,  all  these  precautions  are 
in  the  aggregate  justifiable  and  reasonal)le. 

Care  of  Other  Excretions. — The  urine  and  feces  are  to  be  con- 
sidered secondary  in  importance  to  the  sputum,  but  soiled  undercloth- 
ing and  bedding  should  be  soaked  before  being  handled  in  a  laundry,  and 
especially  where  renal,  vesical,  or  intestinal  tuberculosis  is  known  to  be 
present.  Abrasions  of  the  genital  organs,  especially  of  the  female, 
should  be  kept  surgically  clean  in  the  tuberculous. 

Duty  of  Consumptive  Individual  to  Society. — Every  tuberculous  per- 
son owes  a  duty  to  his  fellow  human  beings  to  the  extent  of  protecting 
them  so  far  as  possible  from  his  disease.  He  cannot  rightfully  scatter 
infection  about  because  it  is  some  trouble  and  sacrifice  for  him  to  avoid 
this,  and  because  he  may  have  acquired  the  disease  through  no  fault 
of  his  own.  Xay,  more,  he  may  not  justify  carelessness  if  his  disease 
is  the  direct  and  acknowledged  result  of  public  neglect.  The  rule  must 
apply  here  as  in  all  infectious  diseases,  although  restraint  of  freedom 
beyond  recognized  limits  is  very  much  less  justified.  Quarantine  of  a 
tuberculous  patient  cannot  be  upheld  unless  he  is  sho\ATi  to  be  viciously 
dirty  and  knowingly  careless.  Isolation  for  the  tuberculous  insane  and 
imbecile  or  the  hopelessly  ignorant  and  depraved  patient  is  logically 
demanded,  but  not  for  the  intelligent  and  obedient  in  the  present  state 
of  society  and  widespread  prevalence  of  the  disease. 

On  the  part  of  the  patient,  voluntary  isolation  cannot  be  expected, 
yet  it  is  desirable  that  he  should  avoid  undue  publicity  in  manifesting 
the  symptoms,  which  may  cause  him  embarrassment  and  increase  the 
prejudice  of  the  inconsiderate  public.  This  is  especially  true  of  ad- 
vanced cases  with  severe  cough  and  hoarseness  when  in  public  places, 
such  as  street  cars,  waiting  rooms,  theaters,  churches,  hotels,  and  espe- 
cially restaurants. 

Duty  of  Society  to  Consumptive  Individual. — The  careful,  cleanly 
consumptive  has  a  right  to  associate  with  other  people  in  the  ordinary 
pursuits  of  business  and  pleasure.  He  also  should  have  the  right  to 
consideration  and  sympathy  as  well  as  charitable  aid  when  in  need. 
He  can  justl}^  meet  the  demands  of  society  for  his  isolation  or  abandon- 
ment of  occupation  by  the  counter  demand  for  a  place  of  retreat  or 
another  occupation.  Society,  through  government,  should  provide  in- 
struction to  the  afflicted  individual  in  the  means  of  prevention  and  cure, 
and  not  greatly  restrict  his  liberty  provided  he  obeys  these  instructions. 


ADDENDA  409 

Phthisiopliohia  has  been  an  increasingly  serious  matter  for  several 
years,  and  the  popular  lecturer  on  tuberculosis  cannot  avoid  conveying 
exaggerated  ideas  of  the  dangers  of  infection.  When  the  public  is  told 
that  a  dirty  consumptive  is  dangerous,  the  inference  that  all  consump- 
tives are  dangerous  is  irresistible  to  many  persons.  Argument  and  sta- 
tistics do  not  accomplish  much  to  counteract  this  unjust  impression,  and 
it  behooves  all  right-minded  physicians  to  throw  the  weight  of  their  per- 
sonal influence  against  exaggeration. 

Marriage  should  not  be  contracted  by  tuberculous  persons  until  two 
years  after  their  recovery,  except  under  special  conditions.  Where  a 
complete  arrest  of  the  disease  is  obtained,  though  not  a  clinical  cure, 
marriage  and  procreation  may  sometimes  be  permitted  with  safety  under 
favorable  conditions  of  life  in  other  respects.  Circumstances  arise 
wliere  the  marriage  of  consumptives  is  quite  justifiable,  but  in  nearly 
all  of  these  cases  the  procreation  of  offspring  should  be  forbidden  in  a 
consumptive  wife.  The  interest  of  the  mother  and  child  alike  demand 
this  course,  yet  if  pregnancy  occurs,  the  induction  of  abortion  becomes 
a  question  to  be  decided  in  each  case  and  not  by  rule.  When  the  hus- 
band is  consumptive,  the  interest  of  the  mother  and  child  are  less  en- 
dangered, but  usually  sufficiently  so  as  to  preclude  procreation.  Con- 
siderations of  a  nonmedical  character  must  frequently  determine  the 
decision  and  remove  the  matter  from  the  physician's  control. 


ADDENDA 

Summary   of  Individual  Prophylaxis,  Presented  at   the   International 
Congress,  held  in  Washington,  D.  C. 

While  no  fundamentally  new  contributions  have  been  made  to 
methods  of  individual  prophylaxis,  a  great  number  of  investigations  of 
tuberculosis  in  childhood  have  again  emphasized  the  necessity  of  pur- 
poseful efforts  in  early  childhood. 

The  enormous  number  of  infected  children  is  only  recently  becom- 
ing realized  and  emphasized  by  the  results  of  examinations.  Miller  and 
Woodruff  found  51  per  cent  in  150  children  of  tuberculous  parentage. 
Floyd  and  Hawes  in  900  children  found  66  per  cent  distinctly  tubercu- 
lous, the  majority  of  whom  were  exposed  at  home.  Lowman  and  Sachs 
have  also  found  similar  conditions. 

Suggestive  as  regards  the  attempted  immunization  of  children  by 
feeding  them  with  milk  from  immunized  animals  is  W.  J.  Butler's 
finding  that  opsonic  substances  are  practically  absent  in  milk  of  healthy 
women. 


CHAPTER   II 

PUBLIC   MEASURES   IN   THE   PEOPHYLAXIS    OF 
TUBERCULOSIS 

By  S.  ADOLPHUS  KNOPF 

Historical  Review. — The  possibility  of  the  transmission  of  tubercu- 
lous diseases,  particularly  pulmonary  tuberculosis  from  man  to  man,  was 
known  to  some  of  the  ancient  Greek  and  Arabian  physicians.  Galen 
(131-200  A.D.)  was  the  first  to  write  of  the  possible  contagiousness  of 
the  disease,  and  Avicenna  (980-1037  a.d.),  the  founder  of  the  Arabian 
school  of  medicine,  speaks  of  the  contagiousness  of  phthisis  pulmonalis 
in  his  "  Arabum  medicorum  principis  "  and  the  "  Canon  medicinge." 

The  first  scientific  demonstration  of  the  transmission  of  tul)erculosis 
from  man  to  animal  was  given  by  the  French  physician  Villemin,  in 
1865,  and  the  infectiousness  of  tuberculous  meat  and  milk  from  tuber- 
culous cattle  was  first  shown  by  Gerlach  and  Klebs  in  1870. 

The  first  official  act  pronouncing  tuberculosis  a  contagious  disease, 
giving  directions  for  the  disinfection  of  apartments,  furniture,  and  per- 
sonal effects  used  by  a  consumptive,  making  it  at  the  same  time  obliga- 
tory for  the  physician  to  report  cases  of  consumption  to  the  authorities 
and  prescribing  the  punishment  for  failure  to  do  so,  was  the  celebrated 
royal  decree  issued  in  Naples,  September  20,  1782.  With  the  beginning 
of  the  nineteenth  century,  however,  it  was  no  longer  enforced. 

After  that,  for  nearly  a  hundred  years,  there  were  only  individual 
efforts  on  the  part  of  some  public  officers  or  local  governments  to  recog- 
nize in  tuberculosis  a  communicable  disease.  A  new  impulse  toward 
the  recognition  of  the  necessity  of  taking  proper  precautions  and  edu- 
cating the  public  in  regard  to  tuberculosis  as  an  infectious  disease,  was 
given  through  the  epoch-making  discovery  of  the  tubercle  bacillus  by 
Robert  Koch  in  1882.  Soon  after  that  laws  were  made  and  official 
regulations  issued  in  various  countries  with  the  object  of  the  prevention 
of  tuberculosis  in  men  and  animals.  The  first  society  for  the  prevention 
of  tuberculosis  in  the  United  States  was  founded  in  1892  by  Dr.  Law- 
rence F.  Flick,  of  Philadelphia. 

France  had  its  first  "  Congres  pour  I'Etude  de  la  Tuberculose  ehez 
riiommc  et  cliez  les  animaux  "  in  1898,  Germany  held  a  congress  at 
410 


HISTORICAL   REVIEW  411 

Berlin  in  1890,  and  England  followed  with  one,  international  in  scope, 
in  1901.  There  was  a  similar  congress  held  at  Naples  in  1906.  A  truly 
international  congress  on  tuberculosis  convened  in  Paris  in  1905.  At 
the  closing  session  of  this  congress  it  was  decided  to  hold  the  next  one 
in  Washington  in  the  autumn  of  1908,  under  the  auspices  of  the  Na- 
tional Association  for  the  Study  and  Prevention  of  Tuberculosis. 

This,  the  first  congress  of  its  kind  ever  held  in  the  United  States, 
must  be  considered  one  of  the  most  successful  scientific  gatherings  which 
ever  convened.  Mr.  Theodore  Poosevelt  accepted  the  presidency  of  the 
congress,  Koch  of  Berlin.  Williams  of  London,  and  Landouzy  of  Paris 
were  made  honorary  presidents,  the  governors  of  the  various  States  of 
the  Union  acting  as  honorary  vice-presidents;  representatives  from  all 
civilized  nations  were  sent,  and  the  attendance  was  very  large. 

Many  valuable  communications  were  presented  at  the  section  meet- 
ing. There  were  seven  of  these  sections:  Section  I,  "Pathology  and 
Bacteriology,"  Dr.  William  H.  Welch,  president;  Section  II,  "Clinical 
Study  and  Therapy  of  Tuberculosis — Sanatoria,  Hospitals,  and  Dispen- 
saries," Dr.  Vincent  Y.  Bowditch,  president;  Section  III,  "  Surgery  and 
Orthopedics,"  Dr.  Charles  H.  Mayo,  president ;  Section  IV,  "  Tuber- 
culosis in  Children,"  Dr.  Abraham  Jacobi,  president;  Section  V,  "Hy- 
gienic, Social,  Industrial,  and  Economic  Aspects  of  Tuberculosis."  Mr. 
Edward  T.  Devine,  president;  Section  VI,  "State  and  Municipal  Con- 
trol of  Tuberculosis,"  Surgeon-General  Walter  Wyman.  president ;  Sec- 
tion VII,  "  Tuberculosis  in  Animals  and  its  Relations  to  Man,"  Dr. 
Leonard  Pearson,  president. 

The  meetings  were  held  in  the  new  National  Museum,  which  the 
L^nited  States  Government  had  placed  at  the  disposal  of  the  congress. 
The  tuberculosis  exhibition  was  held  in  the  same  building,  and  it  can 
be  said  that  it  was  the  most  instructive  ever  presented.  The  exhibition 
consisted  of  charts,  photographs,  maps,  models,  diagrams,  and  all  sorts 
of  appliances  for  the  prevention,  study,  and  treatment  of  tuberculosis. 
Exhibits  were  shown  from  15  different  countries,  and  from  200  asso- 
ciations and  individuals.  All  in  all  the  exhibition  included  nearly 
5,000  units.  Numerous  awards,  prizes,  and  honorable  mentions  were 
given.  There  were  nearly  7,000  inscribed  congress  members.  Some  of 
the  distinguished  foreign  delegates  delivered  special  addresses  in  Wash- 
ington and  other  cities  of  the  Union.  The  section  meetings  lasted 
from  September  28th  to  October  3d,  and  the  social  functions  of  the 
congress  were  as  interesting  and  gratifying  as  the  scientific  work.  At 
the  concluding  session,  over  which  Secretary  Cortelyou  presided,  Presi- 
dent Roosevelt  made  an  interesting  and  inspiring  address.  The  dele- 
gates present  decided  to  accept  the  invitation  from  the  Italian  Govern- 
ment to  hold  the  next  coTi<rr('ss  in  Rome  in  1911. 


412    PUBLIC  MEASURES  IN  THE   PROPHYLAXIS  OF   TUBERCULOSIS 

A  few  historic  details  from  this  country  may  be  referred  to.  The 
first,  and  one  of  the  most  important,  a  tuberculosis  committee,  was 
founded  in  1902  by  the  Charity  Organization  Society  of  Xew  York. 
Since  then  numerous  similar  committees,  local  and  State  organizations 
have  been  founded. 

The  national  concentration  of  the  work  was  brought  about  in  1904 
through  the  foundation  of  the  National  Association  for  the  Study  and 
Prevention  of  Tuberculosis,  at  a  meeting  in  Philadelphia.  Its  organi- 
zation was  completed  in  June  of  that  year,  at  the  time  of  the  meeting 
of  the  American  Medical  Association  at  Atlantic  City.  The  officers 
elected  were :  Edward  L.  Trudeau,  president ;  William  Osier  and  Herr- 
man  M.  Biggs,  vice-presidents;  Henry  Barton  Jacobs,  secretary;  and 
General  George  M.  Sternberg,  treasurer.  Theodore  Eoosevelt  and  the 
late  Grover  Cleveland  were  among  the  honorary  vice-presidents.  The 
offices  of  the  association  are  in  New  York  City  (United  Charities  Build- 
ing, 105  East  Twenty-second  Street). 

Dr.  Livingston  Farrand,  the  present  executive  secretary  of  the  asso- 
ciation, reports  on  the  gratifying  progress  made  in  antituberculosis 
work  in  the  United  States.  The  great  success  is  in  no  small  measure 
due  to  the  activity  of  the  National  Association  and  of  this  efficient 
executive  officer.  His  report  states  that  there  exist  in  the  United 
States  at  the  present  time  195  antituberculosis  associations,  240  sana- 
toria and  special  hospitals  for  the  tuberculous,  and  158  dispensaries 
exclusively  devoted  to  the  treatment  and  instruction  of  ambulant  tuber- 
culous patients.^ 

The  National  Association  is  a  member  of  the  International  Anti- 
tuberculosis Association,  which  has  its  central  bureau  in  Berlin  (Knese- 
beckstrasse,  29,  general  secretary,  Dr.  Pannwitz).  This  latter  association 
has  as  members  representatives  from  all  the  countries  of  the  world  in 
which  systematic  efforts  against  tuberculosis  are  carried  on.  Twenty- 
two  countries  are  at  present  represented  with  a  total  membership  of 
about  800. 

The  object  of  the  association  is  to  encourage  those  efforts  against 

'  At  the  present  moment  the  status  is  as  follows: 

Associations:  Increase 

Number  August  1,  1908 195 

Number  March  15,  1909 273         78 

Sanatoria: 

Number  August  1,  1908 240 

Number  March  15,  1909 289         49 

Dispensaries: 

Number  August  1,  1908 158 

Number  March  15,  1909 217         59 


THE  POPULAR  LECTURE  413 

tuberculosis  which  require  international  cooperation.  These  include 
comparative  studies  of  law  and  police  regulations  in  regard  to  the  dis- 
ease, notification,  disinfection,  segregation  of  advanced  cases,  insurance 
against  sickness  and  invalidity,  occupational  hygiene,  the  hygiene  of  the 
home,  etc.  The  introduction  of  uniform  methods  of  gathering  statistics, 
investigations  in  regard  to  the  spread  of  tuberculosis  to  other  countries 
and  races  are  included,  and,  finally,  the  scientific  inquiry  into  the  causes 
of  tuberculosis  (routes  of  infection,  heredity  and  predisposition,  etc.), 
and  of  methods  of  treatment. 

For  the  discussion  of  these  problems  annual  conferences  of  the  asso- 
ciation are  held.  The  association  also  publishes  a  monthly  journal, 
Tuberculosis,  in  three  languages.  This  Journal  is  now  in  its  eighth 
year  with  a  circulation  of  nearly  3,000.  A  detailed  report  on  the  work 
done  by  the  International  Antituberculosis  Association  was  presented  at 
the  last  congress  by  Helm. 

Purpose  and  Scope  of  Local  Antituberculosis  Associations. — The 
purpose  and  scope  of  these  associations  or  committees  should  be:  first, 
the  promulgation  of  the  doctrine  that  tuberculosis  is  communicable  and 
preventable;  second,  the  dissemination  through  public  lectures,  exhibi- 
tions with  demonstrations,  distribution  of  literature,  etc.,  of  knowledge 
concerning  the  means  and  methods  of  preventing  tuberculosis;  third, 
the  promotion  of  all  movements  which  will  provide  for  the  tuberculous 
dispensary  facilities  and  advice  stations  (class  methods),  camps,  sana- 
toria, and  special  hospitals;  fourth,  the  promotion  of  all  efforts  tending 
to  prevent  the  development  of  tuberculosis  and  scrofulous  diseases  by 
improving  the  condition  of  tenements,  the  erection  of  model  dwellings, 
the  creation  of  parks,  roof  gardens,  recreation  piers,  playgrounds,  gar- 
den schools,  baths,  gymnasiums,  etc. ;  fifth,  cooperation  with  local  munici- 
pal, State,  or  federal  authorities  with  a  view  of  enacting  and  enforcing 
laws  and  regulations  against  indiscriminate  spitting,  the  use  of  meat 
and  milk  from  tuberculous  animals,  and  for  the  obligatory  notifica- 
tion of  all  cases  of  tuberculosis  to  the  local  health  authorities.  These 
plans  should  be  carried  out  without  imdue  hardships  to  the  tuberculous 
invalid  and  their  families,  or  to  farmers  and  dairy  men. 

The  Popular  Lecture. — This  is  best  delivered  by  a  general  practi- 
tioner, preferably  a  member  of  the  local  tuberculosis  society.  It  is  well 
to  have  several  physicians  alternate  in  the  task.  A  public  hall  or  school- 
house,  easily  accessible,  well  lighted  and  ventilated,  is,  of  course,  the 
most  suitable  place  for  this  purpose.  It  will  not  do  to  lecture  on  tuber- 
culosis and  on  the  value  of  light  and  pure  air  in  a  gloomy,  badly  ven- 
tilated hall.  The  lecture  must  be  free  to  all,  and  delivered  at  a  time 
when  the  masses  can  come  to  listen.  The  titles  of  the  lectures  should 
not  be  grewsome;  they  should  be  dignified,  encouraging,  and  inviting — 


414    PUBLIC  MEASURES  IN  THE  PROPHYLAXIS  OF  TUBERCULOSIS 

for  example,  such  as  the  following,  which  the  writer  has  used  with  suc- 
cess :  "  Our  Duties  Toward  the  Consumptive  Poor,"  "  The  Tuberculosis 
Problem  and  How  it  may  be  Solved,"  "  The  Prevention  of  Tubercu- 
losis," "  The  Joyful  Message  of  the  Preventability  and  Curability  of 
Tuberculosis,"  "  Pulmonary  Consumption  and  the  Possibilities  of  its 
Eradication  Through  the  Combined  Action  of  a  Wise  Government, 
Well-trained  Physicians,  and  an  Intelligent  People,"  "  The  Victory 
Over  the  Great  White  Plague,"  "  The  Social  and  Humanitarian  Aspects 
of  the  Tuberculosis  Problem,"  "  The  Duties  of  the  Government  and 
the  Individual  in  the  Combat  of  Tuberculosis,"  "  The  Successful  War- 
fare Against  Tuberculosis." 

If  the  audience  is  to  be  composed  of  women  or  school  teachers,  it 
is  well  to  select  titles  similar  to  the  following :  "  Women's  Duty  in  the 
Fight  Against  Tuberculosis,"  "The  Teacher's  Part  in  the  Antituber- 
culosis Crusade." 

Handbills  and  Invitations  to  Lectures. — The  handbills,  circulars, 
or  cards  inviting  a  general  or  a  special  public  to  attend  a  lecture,  should 
be  attractive  and  to  the  point.  If  it  can  be  announced  that  a  prominent 
officer  of  the  city  or  State  will  preside  over  the  meeting,  it  will  add 
to  the  prestige  of  the  movement  and  be  likely  to  attract  a  larger  audi- 
ence. 

It  has  sometimes  been  the  experience  of  the  writer,  as  an  occasional 
lecturer  before  public  audiences,  to  be  requested  by  the  committee  on 
arrangement  to  avoid  the  words  tuberculosis  or  consumption  in  the  title 
of  his  lecture.  It  was  thought  by  the  committee  that  too  suggestive 
titles  might  keep  a  number  of  sensitive  people  away.  Such  titles  as, 
for  example,  "  How  May  the  Health  of  Our  Community  be  Improved  ?  " 
"  A  Health  Problem  of  Interest  to  Everybody,"  "  Health  and  Prosperity 
and  How  it  may  be  Furthered,"  might  then  be  used. 

Economic  Loss  to  the  Commonwealth  through  Tuberculosis. — In  a 
public  lecture  on  tuberculosis  it  is  well  to  point  out  strongly  the  eco- 
nomic loss  accruing  to  a  community  which  does  not  take  care  of  its 
consumptive  poor  at  the  right  time  and  at  the  right  place  when  there 
is  the  best  possible  chance  for  recovery,  but  waits  until  it  is  too  late 
and  then  cares  for  them  at  the  wrong  place  (county  hospital  or  poor 
farm).  It  is  best  to  make  such  calculations  with  direct  reference  to 
the  locality  in  which  the  lecture  is  delivered.  Thus,  for  example,  in 
my  own  city  and  State  I  have  been  in  the  habit  of  giving  to  my  lay 
audience  the  following  convincing  figures :  It  is  estimated  that  there  are 
in  this  State  about  50,000  tuberculous  invalids.  Of  these  probably  one 
fifth  belong  to  that  class  of  patients  who  sooner  or  later  become  a  burden 
to  the  community.  These  10,000  consumptives,  absolutely  poor,  will 
sooner  or  later  have  to  be  taken  care  of  by  the  public  general  hospitals. 


LOSS  TO  THE  COMMONWEALTH  THROUGH  TUBERCULOSIS     415 

While  tlu'v  may  not  stay  in  one  hospital  twelve  months  continuously, 
they  will  certainly  occupy  a  bed  in  one  or  other  of  the  public  institu- 
tions for  that  length  of  time  before  they  die.  According  to  a  recent 
report  by  the  public  charity  hospitals  of  Xew  York  City,  the  average 
cost  per  patient  per  day  in  the  general  hospital  is  $1.16.  Thus,  the 
cost  to  the  commonwealth  will  be  $4,234,000  per  year  for  caring  for 
the  10,000  consumptives. 

What  would  l)e  the  expense  if  they  were  taken  care  of  in  a  sana- 
torium? Experience  in  this  country  has  demonstrated  that  the  main- 
tenance of  incipient  cases  in  well-conducted  sanatoria  can  well  be  car- 
ried out  for  $1  per  day.  If  these  10,000  persons  should  be  sent  to 
a  sanatorium  in  time,  at  least  6,000  of  them  would  he  cured  perma- 
nently after  a  maximum  sojourn  of  two  hundred  and  fifty  days,  at  an 
average  expense  of  $250  per  capita.  Thus,  for  $1,500,000,  6,000  per- 
sons would  again  become  breadwinners  and  useful  citizens.  If  the 
remaining  4,000  invalids  were  kept  in  the  sanatorium  one  year  before 
they  died,  it  would  cost  $1,460,000.  Thus,  taking  away  from  the  tene- 
ment districts  10,000  consumptives,  curing  more  than  half  of  them, 
caring  for  the  other  half,  and  destroying  10,000  foci  of  infection  will 
cost  $2,960,000.  When  not  taken  care  of  in  the  earlier  stages  of  this 
disease  they  will  probably  all  die,  since  this  10,000  represents  the  abso- 
lutely poor  who  now  live  under  most  unhygienic  conditions;  they  will 
have  infected  a  perhaps  equally  large  or  larger  number  of  individuals 
living  with  them,  but  before  dying  they  will  have  cost  the  community 
$4,234,000. 

Another  valuable  argument  which  may  w^ell  be  presented  in  any 
public  lecture  is  that  relating  to  the  loss  which  accrues  to  a  community 
by  failing  to  prevent  its  people  from  becoming  tuberculous.  Besides 
the  loss  and  sorrow  which  are  naturally  felt  by  the  individual  and 
family,  the  economic  loss  from  tuberculosis  sustained  by  the  common- 
wealth is  tremendous.  Dr.  Thomas  Darlington,  the  Health  Commis- 
sioner of  New  York  City,  in  speaking  of  the  cost  of  tuberculosis  in  that 
city,  declares  in  a  recent  publication :  "  Estimating  the  value  of  a  single 
life  at  $1,500 — not  necessarily  a  high  estimate — and  taking  only  the  lives 
between  sixteen  and  forty-five  years,  the  monetary  loss  of  life  in  that 
city  alone  from  tuberculosis  amounts  to  the  startling  sum  of  $23,000,- 
000  annually." 

Dr.  John  B.  Huber,  also  a  close  observer,  estimates  that  tubercu- 
losis occasions  to  the  United  States  an  annual  loss  of  at  least  $330,- 
000,000.  One  tenth  part  of  this,  judicially  spent,  at  the  right  time  and 
at  the  right  place,  for  prevention  would  probably  suffice  to  eradicate 
the  disease  within  a  very  few  years.  This  fact  should  always  be  im- 
pressed upon  a  public  audience. 


416    PUBLIC  MEASURES  IN  THE   PROPHYLAXIS  OF  TUBERCULOSIS 

Protest  against  Patent  Medicines  and  "  Sure  Consumption  Cures." 

— It  should,  furthermore,  never  he  forgotten  in  a  puhlic  lecture  that 
much  good  may  be  accomplished  by  a  dignified  protest  against  the  use 
of  patent  medicines  and  the  dangerous  and  nefarious  trade  of  quacks 
who  advertise  "  sure  consumption  cures,"  claiming  some  secret  method 
or  remedy.  A  very  valuable  pamphlet  has  been  issued  by  our  New 
York  Department  of  Health  on  so-called  "  consumption  cures,"  It 
ought  to  circulate  in  every  community,  and  with  the  substitution  of 
the  names  of  prominent  local  physicians  instead  of  those  of  the  New 
York  ones.  I  am  convinced  that  such  a  circular  would  do  much  toward 
convincing  the  people  that  all  the  so-called  sure  and  quick  consumption 
cures  advertised  as  sv^ch  are  invariably  based  on  false  claims. 

Character  of  a  Tuberculosis  Lecture. — The  lecture  itself  should,  of 
course,  be  practical  and  to  the  point,  avoiding  too  technical  and  too 
scientific  expressions.  It  is  not  always  easy  to  speak  the  language  of 
science  in  the  language  of  the  people,  but  one  should  strive  to  use  plain, 
simple  words  and  make  himself  well  understood.  While  a  dignified 
and  earnest  manner  will  always  appeal  to  an  intelligent  audience,  the 
lecture  should  be  enlivened  with  some  bright,  cheerful  suggestions, 
and  even  an  occasional  witty  remark  may  find  its  place.  If  the  lecturer 
is  able  to  speak  extemporaneously,  it  is  always  the  most  appealing  and 
successful  way  to  reach  a  popular  audience.  But  whether  the  address 
is  extemporaneous  or  read  from  manuscript,  it  should  not  exceed  three 
quarters  of  an  hour  in  length.  The  remaining  quarter  of  an  hour 
should,  whenever  possible,  be  devoted  to  showing  stereopticon  views, 
illustrating  devices  for  the  prevention  and  treatment  of  tuberculosis, 
such  as  sputum  cups,  reclining  chairs,  window  tents,  chair  half  tents, 
sleeping  tents,  sleeping  shacks,  lean-tos,  sanatoria  and  special  hospitals. 

To  illustrate  by  charts  or  lantern  slides  the  absolute  and  relative 
mortality  from  tuberculosis  in  a  given  locality,  and  also  to  show  by 
tables  which  occupations  are  particularly  conducive  to  the  contraction 
of  tuberculosis,  is  always  interesting  and  most  instructive  to  a  lay 
audience.  While  even  the  illustrations  of  bacilli  may  be  useful  and 
interesting,  it  hardly  seems  wise  to  show  a  popular  audience  reproduc- 
tions of  pathologic  specimens,  such  as  decayed  lungs,  etc. 

No  public  lecture  on  tuberculosis  is  ever  complete  or  will  ever  fulfill 
its  mission  without  an  ardent  remonstrance  against  phthisiophobia — 
that  insane,  exaggerated  fear  of  the  presence  of  consumptives  as  such. 
In  the  chapter  on  individual  prophylaxis,  Dr.  Baldwin  has  explained 
the  simple  measures  by  which  the  consumptive  may  protect  others  from 
infection  and  himself  from  reinfection,  thus  plainly  showing  the  folly 
of  individual  phthisiophobia.  In  a  popular  lecture  it  should  be  de- 
clared emphatically  that  the  clean,  conscientious  consiimptive  who  takes 


UNJUSTIFIED   PREJUDICE  AGAINST   CONSUMPTIVES  417 

care  of  his  expectoration  is  no  more  a  source  of  danger  to  his  fellow- 
men  than  any  healthy  citizen. 

Unjustified  Prejudice  against  Consumptives. — But  besides  this  indi- 
vidual fear  of  the  presence  of  the  consumptive  on  account  of  his  disease, 
there  is  another  prejudice  based  on  his  alleged  different  and  peculiar 
mentality.  People  forget  that  among  the  consumptive  invalids  of  the 
past  and  the  present  there  have  been  and  are  some  of  the  best  types  of 
manhood  and  womanhood — useful,  noble,  and  valuable  citizens,  humani- 
tarians, scientists,  and  philanthropists.  The  idea  prevails  among  lay. 
I^eople,  and  now  and  then  even  among  medical  men,  that  the  average 
pulmonary  invalid  is  mentally  and  morally  inferior  to  the  average 
healthy  individual  or  one  afflicted  with  some  other  infirmity. 

A  few  years  ago,  when  preparing  an  address  entitled  "  A  Plea  for 
Justice  to  the  Consumptive,"  which  was  read  before  the  Kew  York 
Society  of  ]\redical  Jurisprudence,  as  a  reply  to  recent  attempts  to  dis- 
criminate against  the  consumptive,  the  writer  solicited  the  opinions  of 
leading  medical  authorities  on  this  subject,  which  served  well  as  a 
rebuke  to  those  daring  to  make  the  statement  that  because  an  individual 
is  tuberculous  he  is,  therefore,  mentally  unsound  or  more  inclined  to 
immorality  and  selfishness  than  any  other  individual. 

One  of  these  authorities,  Dr.  E.  L.  Trudeau,  says : 

I  have  never  noticed  any  greater  tendency  to  immorality  or  crime  among 
consumptives  than  is  to  be  found  in  the  average  of  the  human  race,  as  far 
as  it  has  come  under  my  observation.  On  the  contrary,  I  have  seen  all 
the  finer  traits  of  the  human  nature  developed  to  the  fullest  extent  by  the 
burdens  Avhich  chronic  and  fatal  illness,  often  slow  in  its  progress,  adds  to 
the  sum  total  of  what  men  and  women  usually  have  to  endure  in  life.  I 
have  seen  certainly  more  patience,  courage,  self-denial,  and  unselfish  devo- 
tion to  others  in  consumptives  than  I  have  noticed  in  the  majority  of 
healthy  human  beings.  Indeed,  the  sanatorium  work  never  could  have  been 
carried  on  were  it  not  for  the  self-sacrificing  devotion  to  the  suffering  of 
others  shown  by  my  associates,  the  nurses,  and  even  the  employees  at  the 
sanatorium,  most  of  them  having  come  here  originally  because  suflFering 
from  tuberculous  disease.  Historj^  is  full  of  instances  which  prove  that 
tuberculosis  does  not  interfere  with  the  development  to  the  highest  degree 
of  the  intellectual,  the  moral,  or  the  ethical  sides  of  man's  nature. 

It  would  hardl}^  seem  necessary,  after  such  opinions  expressed,  for  the 
writer  to  add  his  own  opinion,  though  based  on  an  experience  of  many 
years  of  practice  among  consumptives  in  different  climes  and  different 
countries,  and  among  men  and  women  in  all  stations  of  life.  The  writer 
has  not  only  practiced,  but  also  lived  among  them  and  with  them, 
and  from  all  his  experience  he  can  only  confirm  what  has  been  said 

bv  others.     Xever  has  he  noticed  consumptives  to  be  more  inclined  to 

28 


418    PUBLIC  MEASURES  IN  THE   PROPHYLAXIS  OF  TUBERCULOSIS 

immorality  or  crime  than  individuals  afflicted  with  other  diseases,  or 
even  well  people;  in  only  a  few  instances  has  he  noticed  real  selfishness, 
and  never  what  one  could  call  a  distortion  of  the  clearness  of  ethical 
perception.  On  the  contrary,  as  in  the  experience  of  Drs.  Osier,  Jane- 
way,  Trudeau,  and  Bowditch,  it  has  always  seemed  to  him  that  many 
consumptives  are  ahove  the  average  in  their  mental  and  moral  char- 
acteristics. Instead  of  brute  selfishness,  the  writer  has  frequently  wit- 
nessed the  most  touching  evidences  of  self-sacrifice  and  devotion.  He 
has  seen  colleagues  in  institutional  and  private  practice,  trained  nurses 
and  sisters  of  charity,  who.  though  they  knew  they  had  contracted  tuber- 
culosis in  the  pursuit  of  their  professional  duties,  did  not  leave  the 
battlefield,  but  continued  to  labor  and  help  their  consumptive  fellow- 
sufferers.  Two  of  the  writer's  most  beloved  teachers,  to  whom  he  owes 
an  everlasting  debt  of  gratitude  for  the  inspiration  and  help  they  have 
given  him  in  his  work,  Professor  Grancher,  of  Paris,  and  Geheimrath 
Dettweiler,  of  Falkenstein,  were  both  consumptives.  They  taught  and 
practiced  among  consumptives  for  a  quarter  of  a  century,  and  were 
leaders  in  the  antituberculosis  crusade  in  Europe  until  the  very  last 
days  of  their  lives.  Dr.  Dettweiler  died  in  1904  and  Professor  Grancher 
in  1907. 

Among  the  sweetest  experiences  and  recollections  of  his  life,  the 
writer  will  always  count  the  gratitude  of  the  consumptive,  poor  or  rich, 
expressed  either  on  the  assurance  of  their  recovery  or  for  the  care  be- 
stowed on  them  when  their  case  was  beyond  human  help. 

Federal  Phthisiophobia. — Occasionally,  besides  a  private  or  indi- 
vidual phthisiophobia,  there  exists  also  what  may  justly  be  called  an 
official  phthisiophobia.  It  is  manifested,  for  example,  in  efforts  to  ex- 
clude consumptive  individuals  from  certain  states  or  countries,  or  in 
hindering  efforts  to  build  sanatoria  and  special  hospitals. 

While  the  practice  of  getting  rid  of  the  consumptive  poor  in  one 
locality  by  sending  them  to  other  States  is  contemptible  and  should  be 
unlawful,  it  must  be  considered  cruel  and  inhumane  to  exclude  from  any 
state  or  country  the  Avell-to-do  tuberculous  invalid  who  is  willing  to 
o])ey  all  the  sanitary  regulations  which  will  make  him  no  longer  a  source 
of  danger.  Equally  inhumane  and  unwise  are  any  laws  and  regulations 
that  make  the  establishment  of  institutions  difficult,  as,  for  example, 
the  law,  known  as  the  Goodsell-Bedell  law,  which  was  signed  by  Gov- 
ernor Odell,  the  then  governor  of  the  State  of  New  York.  The  subject 
of  official  phthisiophobia  is  such  an  important  one  to  all  physicians 
and  public-spirited  citizens  interested  in  the  crusade  against  tubercu- 
losis, that  in  dealing  with  it  the  writer  feels  justified  in  reproducing 
in  substance  what  he  said  on  the  subject  in  the  above-mentioned  address, 
entitled  "  A  Plea  for  Justice  to  the  Consumptive." 


FEDERAL   PHTHISIOPHOBIA  419 

Official  plitliisiophobia  started  in  the  United  States  about  two  years 
ago,  when  the  Surgeon-General  of  the  Public  Health  and  Marine  Hos- 
pital Service  issued  a  declaration  that  pulmonary  tuberculosis  must  be 
classed  as  a  dangerous  contagious  disease,  and  that  in  future  immigrants 
or  aliens  visiting  our  shores  afflicted  with  pulmonary  tuberculosis  must 
be  debarred  from  all  ports  of  the  United  States.  In  June,  1907, 
an  order  was  issued  confirming  the  above  decision,  and  adding  that 
tuberculous  individuals  should  be  deban-ed,  regardless  of  boards  of 
special  inquiry  which  heretofore  had  used  tlieir  discretion  in  the 
matter. 

It  goes  without  saying  that  no  one  desires  pauper  immigration,  and 
that  no  one  wants  any  such  class  to  enter  the  country,  whether  they 
are  tuberculous  or  not.  The  question  here  is  simply,  Is  it  right,  just, 
and  scientific  to  declare  pulmonary  tuberculosis  a  dangerous,  contagious 
disease,  and  exclude  on  that  account  worthy  immigrants  w^ho  offer  a 
guarantee  that  they  will  not  become  a  burden  to  the  community,  or  to 
exclude  aliens  or  visitors  afflicted  with  pulmonary  tuberculosis?  Have 
those  who  have  been  instrumental  in  bringing  about  the  government 
decision  to  declare  pulmonary  tuberculosis  a  dangerous,  contagious  dis- 
ease, or  who  favor  this  decision,  ever  thought  of  the  fearful  meaning  of 
a  designation  which  virtually  classes  every  American  consumptive  with 
patients  who  may  be  suffering  from  small-pox,  leprosy,  yellow  fever, 
etc.  ?  Have  they  ever  thought  how  really  few  families  there  are  who 
have  not  at  least  one  more  or  less  near  relative  or  friend  who  is  a 
consumptive?  Tuberculosis  is  the  most  common  of  all  diseases,  and  it 
is  most  prevalent  in  the  pulmonary  form.  It  is  a  disease  of  the  young 
and  old,  of  the  poor  and  rich,  the  East  and  the  West,  the  Xorth  and  the 
South. 

The  following  resolutions  represent  the  consensus  of  opinion  of  the 
medical  profession  on  this  subject  presented  to  the  Xew  York  Acad- 
emy of  Medicine  at  the  time,  and  which  were  seconded  by  Prof.  Edward 
G.  Janeway,  of  that  city,  and  adopted  by  the  Academy  at  its  regular 
meeting  on  February  6,  1902: 

Whereas,  The  Treasury  Department  of  the  United  States,  upon  recom- 
mendation of  the  Surgeon-General  of  the  Marine  Hospital  Service,  has 
recently  decided  to  classify  pulmonary-  tuberculosis  with  dangerous  con- 
tagious diseases,  Be  it 

Resolved,  That  the  New  York  Academy  of  Medicine  deeply  deplores 
this  decision,  which  is  not  based  on  either  clinical  experience  or  on  scien- 
tific experiments.     Be  it  further 

Resolved,  That  the  Academy  considers  the  exclusion  of  nonpauper 
tuberculous  immigrants  and  consumptive  aliens  visiting  our  shores  un- 
wise, inhumane,  and  contrary  to  the  dictates  of  justice.    Be  it  further 


420    PUBLIC  MEASURES  IN  THE  PROPHYLAXIS  OF  TUBERCULOSIS 

Resolved,  That  while  the  Academy  is  convinced  of  the  communicability 
of  tuberculosis  and  urges  all  possible  precautions  against  the  spread  of 
the  disease  occasioned  by  sputum  and  tuberculous  food,  the  Academy  is 
opposed  to  all  measures  by  which  needless  hardship  is  imposed  upon  the 
consumptive  individual,  his  family,  and  his  physician. 

The  secretary  of  the  Academy  was  instructed  to  forward  a  copy  of 
the  resolutions  to  the  Treasury  Department,  the  Surgeon-General  of 
the  Marine  Hospital  Service,  and  to  the  secretary  of  the  New  York 
State  Medical  Society. 

Among  the  many  distinguished  men  who  helped  in  the  support  of 
these  resolutions  are  the  following:  Prof.  Hermann  M.  Biggs;  Prof.  T. 
Mitchell  Prudden;  Prof.  George  M.  Peabody;  Dr.  A.  H.  Doty,  the 
Health  Officer  of  the  Port  of  New  York;  Dr.  August  J.  Lartigau,  of 
the  Bacteriological  Department  of  Columbia  University;  Dr.  George 
B.  Fowler,  ex-president  of  the  New  York  County  Medical  Society;  Dr. 
George  F.  Shrady,  editor  of  the  Medical  Record;  Dr.  Andrew  H.  Smith, 
the  then  president  of  the  New  York  Academy  of  Medicine;  and  Dr. 
Frank  P.  Foster,  editor  of  the  Neiu  York  Medical  Journal. 

Of  leading  editorials  which  appeared  at  the  time  in  American  medi- 
cal journals,  the  following  are  good  examples :  Dr.  George  M.  Gould, 
editor  of  American  Medicine,  said:  "We  think  professional  and  lay 
opinion  will  not  justify  the  exclusion  of  tuberculous  immigrants  on  the 
simple  ground  that  the  disease  is  '  contagious '  or  '  communicable.'  It 
is  only  so  in  such  a  low  degree  that  the  severe  measure  of  expulsion 
for  this  reason  alone  seems  unjustifiable."  Dr.  George  H.  Simmons, 
editor  of  the  Journal  of  the  American  Medical  Association,  the  repre- 
sentative organ  of  the  American  medical  profession,  says  in  regard  to 
the  resolutions :  "  The  resolutions  presented  to  the  Academy  of  Medi- 
cine are  to  the  point  and  express  the  opinion,  I  believe,  of  about  ninety 
per  cent  of  the  best  men  in  the  profession  who  have  given  thought  to  the 
subject."  Dr.  U.  0.  B.  Wingate,  secretary  of  the  Wisconsin  State  Board 
of  Health,  expressed  himself  regarding  this  matter  as  follows:  "The 
action  of  the  head  of  the  Marine  Hospital  Service  in  this  matter  is 
simply  inhuman." 

To  the  best  of  the  writer's  knowledge,  this  almost  universal  protest 
on  the  part  of  the  medical  profession  of  this  country  regarding  the  deci- 
sion of  the  surgeon-general,  acting  under  the  authority  of  the  Treasury 
Department,  has  to  this  date  remained  unheeded. 

State  Phthisiophobia — Goodsell-Bedell  Law. — Before  showing  the 
results  of  federal  official  phthisiophobia  on  the  general  public,  let  us 
consider  state  phthisiophobia.  The  writer  does  not  wish  to  arraign 
the  attempts  of  certain  California  and  Colorado  statesmen  to  exclude 


STATE   PHTHISIOPHOBIA— GOODSELL-BEDELL  LAW  421 

phthisical  invalids  from  their  borders,  but  will  confine  himself  to  the 
State  of  New  York.  Mr.  Benjamin  B.  Odell,  Jr.,  at  that  time  (1903) 
governor  of  this  State,  by  signing  the  Goodsell-Bedell  bill  already  re- 
ferred to,  put  himself  on  record  as  favoring  official  phthisiophobia. 

Under  the  law  of  1900,  chapter  327,  cities  of  the  first  class  were 
authorized  to  erect  sanatoria  for  the  treatment  of  consumptives  outside 
the  city  limits,  such  acts  and  the  selection  of  the  site  to  be  subject  to 
the  approval  of  the  State  and  local  boards  of  health.  Private  property 
was  sufficiently  protected  by  the  general  laws.  The  effect  of  the  Good- 
sell-Bedell law  is  to  make  it  hereafter  practically  prohibitive  to  establish 
such  a  sanatorium  anywhere  in  the  State.  If  any  board  of  supervisors 
of  a  county  or  a  town  board  should  be  opposed  to  the  establishment  of 
an  institution  for  consumptives,  the  mere  adoption  of  resolutions  would 
suffice  to  make  the  erection  of  such  an  institution  impossible. 

The  governor  was  implored  from  all  sides  not  to  sign  the  bill.  The 
New  York  Academy  of  Medicine  protested,  as  it  usually  does  when  there 
is  danger  to  the  public  health  and  welfare  from  injudicious  legislation, 
and  passed  the  following  resolutions  on  the  subject: 

Whereas,  There  has  been  recently  passed  by  the  Legislature  of  the  State 
of  New  York  an  act  to  amend  the  public  health  law  iu  relation  to  the 
establishment  of  public  sanatoria,  hospitals,  or  camps  for  the  treatment 
of  tuberculosis,  which  act  reads  as  follows :  "  A  hospital,  camp,  or  other 
establishment  for  the  treatment  of  patients  suffering  from  the  disease 
known  as  pulmonary  tuberculosis  shall  not  be  established  in  any  town  by 
any  person,  association,  corporation,  or  municipality,  unless  the  Board  of 
Supervisors  of  the  County  and  the  town  board  of  the  town  shall  each 
adopt  a  resolution  authorizing  the  establishment  thereof,  and  describing 
the  limits  of  the  locality  in  which  the  same  may  be  established;"  and 

Whereas,  The  effect  of  this  bill,  if  it  becomes  a  law,  will  make  it  im- 
possible for  any  city  in  the  State,  or  any  fraternal  order,  charitable  society, 
or  philanthropic  individual,  to  establish  a  hospital,  camp,  or  other  estab- 
lishment for  the  treatment  of  consumptives,  outside  of  the  city  limits, 
except  under  conditions  which  are  practically  prohibitive;  and 

Whereas,  By  chapter  327,  of  the  laws  of  1900,  cities  of  the  first  class 
are  authorized  to  erect  sanatoria  outside  of  the  city  limits,  such  action  and 
the  selection  of  a  site  to  be  subject  to  the  approval  of  the  State  Board 
of  Health,  and  by  the  same  law,  hospitals  and  institutions,  now  or  here- 
after established  or  maintained,  are  made  subject  to  the  approval  of  the 
local  board  of  health;  and 

Whereas,  Private  property  rights  are  sufficiently  protected  by  general 
laws,  and  the  process  of  injunction  is  open,  in  case  it  can  be  positively 
shown  that  unwarranted  injury  would  be  inflicted  by  the  establishment  of  a 
hospital  on  a  particuhir  site,  and  the  necessity  of  obtaining  the  consent  of 
the  State  Board  of  Health  being  an  ample  guarantee  that  a  site  shall  not 


422    PUBLIC  MEASURES  IN  THE   PROPHYLAXIS  OF  TUBERCULOSIS 

be  selected  which  shall  threaten  or  unduly  expose  the  health  of  any  par- 
ticular neighborhood ;  and 

Whereas,  It  has  been  demonstrated  in  this  country  and  in  Europe  that 
properly  conducted  sanatoria,  hospitals,  and  camps  for  consumptives  are 
not  a  danger  to  the  neighborhood,  and  that  such  institutions  are  places 
where  the  consumptive  poor  receive  a  hygienic  education,  and  have  the 
best  possible  chances  to  be  cured  and  become  again  useful  citizens  and 
supporters  of  families ;  and 

Whereas,  There  is  at  present  a  great  deficiency  of  hospital  accommoda- 
tion in  New  York  State  for  this  class  of  patients;  Be  it  therefore 

Resolved,  That  the  New  York  Academy  of  Medicine  deeply  deplores  the 
passage  of  the  above  bill,  and  urgently  requests  his  Excellency  the  Gov- 
ernor to  withold  his  signature  to  the  act,  which,  in  case  it  became  a  law, 
would  involve  the  loss  of  thousands  of  lives  and  increase  the  spread  of 
tuberculosis  within  the  crowded  districts  of  our  cities  and  towns,  and  would 
have  to  be  considered  an  act  of  the  greatest  injustice  and  inhumanity. 

In  commenting  on  the  governor's  apology  for  signing  this  bill  in 
spite  of  the  many  protests,  the  editor  of  Charities,  the  organ  of  the 
New  York  Charity  Organization  Society,  says :  "  All  that  we  can  say 
is  that  undue  consideration  seems  to  us  to  have  been  given  to  the 
*  property  interests '  to  which  the  governor  refers  and  none  at  all  to 
the  consumptives,  of  whom  some  20,000  will  die  of  their  disease  in 
the  State  of  New  York  this  year,"  Up  to  the  present  time  (1909)  the 
Goodsell-Bedell  law  still  stands  unrepealed. 

Results  of  Federal  and  State  Phthisiophobia. — What  has  been  the 
result  of  this  Federal  and  State  phthisiopholna  on  smaller  authorities, 
such  as  municipal,  town,  and  village  boards?  Municipalities,  situated 
in  particularly  healthful  regions,  which  formerly  allowed  their  unsuper- 
vised boarding  houses  to  be  crowded  with  consumptives,  which  was  un- 
safe and  unwise,  have  gone  now  to  the  other  extreme,  prohibiting  the 
establishment  or  the  existence  of  well-conducted  sanatoria  in  their  neigh- 
borhoods. Yet  it  is  known  to  all  that  there  is  not  the  slightest  danger 
from  well-conducted  sanatoria;  they  are,  on  the  contrary,  veritable 
schools  of  hygiene,  exerting  a  most  beneficial  influence  by  educating 
the  people  at  large  in  preventive  measures. 

As  soon  as  town  or  village  boards  learn  that  the  establishment  of  a 
sanatorium  is  contemplated  in  the  vicinity  of  their  respective  communi- 
ties, they  come  together  and  oppose  every  movement  favoring  such  a 
plan.  Those  who  are  occasionally  asked  to  help  in  selecting  a  site 
for  a  sanatorium  for  consumptives  will  affirm  that  at  the  present  time 
there  is  nothing  more  difficult  in  New  York  State  than  to  find  a  com- 
munity which  would  welcome  the  establishment  of  such  an  institution. 
The  small  municipalities,  the  towns  and  villages,  are  now  strengthened 


LAW  OF   NEW   MEXICO  AND  GOODSELL-BEDELL   LAW        423 

in  this  insane  prejudice  by  the  Goodsell-Bedell  law.  Yet,  as  it  has 
been  proved  again  and  again  by  most  reliable  statistics,  instead  of  being 
a  danger,  sanatoria  for  consumptives  are  a  blessing  to  the  neighborhood. 
In  the  two  German  villages  Goerbersdorf  and  Falkenstein,  where  five  of 
the  most  flourishing  sanatoria  for  consumptives  have  been  in  existence 
for  the  last  fifty  years,  the  mortality  from  tuberculosis  among  the  in- 
habitants of  the  respective  villages  has  decreased  by  one  third  from 
what  it  was  before  the  establishment  of  these  institutions.  This  remark- 
able result  is  simply  due  to  the  fact  that  the  villagers  voluntarily  imi- 
tate the  hygienic  precautions  which  are  obligatory  on  the  inmates  of 
the  sanatoria. 

Again,  the  well-known  fact  that  in  carefully  conducted  and  well- 
equipped  sanatoria,  where  the  precautions  concerning  the  sputum  are 
most  strictly  adhered  to,  one  is  safer  from  contracting  tuberculosis  than 
perhaps  anywhere  else,  should  open  the  eyes  of  these  narrow-minded 
village  authorities. 

There  is  an  urgent  and  crying  need  for  more  sanatoria  for  the  treat- 
ment of  tuberculous  patients,  and  the  sooner  restrictive  laws,  such  as 
the  Goodsell-Bedell  law,  are  repealed  the  better  it  will  be  for  the  finan- 
cial as  well  as  the  sanitary  conditions  of  the  very  communities  which 
are  now  opposing  the  establishment  of  such  institutions.  These  sana- 
toria educate  and  cure  at  the  same  time;  they  cure  the  curable,  and 
when  patients  are  sent  there  at  the  right  time  they  have  at  least  seventy- 
five  per  cent  of  chances  of  being  cured,  often  in  less  than  a  year's  time. 
Not  treated  and  not  cured,  they  will  cease  to  become  breadwinners,  and 
linger  often  as  burdens  to  the  community  for  one  or  two  years. 

Law  of  New  Mexico  as  a  Contrast  to  the  Goodsell-Bedell  Law. — Of 
historic  interest  and  in  pleasant  contrast  to  the  enactment  of  the  Good- 
sell-Bedell law,  is  the  law  of  New  Mexico  of  1903,  chapter  xvii,  which 
provides  that  any  company  or  corporation  which  shall,  within  one  year 
from  the  passage  of  this  act,  commence  and  within  two  years  after 
the  passage  of  this  act  shall  have  expended  at  least  $100,000  in  the 
construction  of  a  sanatorium  in  New  Mexico  for  the  care  of  invalids 
and  persons  with  tuberculosis  and  other  pulmonary  diseases,  shall  there- 
after be  exempt  from  taxation  on  all  property  actually  used  in  connec- 
tion with  such  sanatorium  for  a  period  of  six  years  after  the  expiration 
of  two  years  after  the  passage  of  this  act. 

It  is  always  Avise  for  the  chairman  of  a  public  meeting,  or  for  the 
lecturer  himself,  to  tell  the  audience  that  they  are  permitted  to  ask  a 
limited  number  of  questions  to  elucidate  points  whicli  may  not  have 
been  understood.  But  almost  invarial)ly  at  the  conclusion  of  such  a 
lecture  a  number  of  the  audience  will  embrace  the  opportunity  to  ask 
the  lecturer  for  some  definite  advice  concerning  their  own  or  some  one 


424    PUBLIC  MEASURES  IN  THE   PROPHYLAXIS  OF  TUBERCULOSIS 

else's  ailment.  There  is  but  one  answer  which  a  conscientious  physician 
can  give  under  such  circumstances,  and  that  is :  "I  am  here  as  a  general 
adviser  and  not  as  an  individual  physician  to  l)e  consulted  for  individual 
ailments.  You  must  seek  medical  advice  where  it  is  always  to  be 
found — in  the  office  of  the  physician.  Tell  your  troubles  to  your  own 
physician,  and  he  will  I)est  know  whether  additional  counsel  is  needed 
or  not." 

Journals  Devoted  to  the  Prevention  of  Tuberculosis. — Persons  in 
the  audience  will  often  ask  the  lecturer  what  they  should  read  in  order 
to  keep  posted  on  things  concerning  tuberculosis.  There  are  three  jour- 
nals published  in  the  United  States  which  are  admirably  adapted  to 
this  purpose:  The  Journal  of  Outdoor  Life  (Trudeau,  N.  Y.),  The 
Survey,  formerly  Charities  and  the  Commons  (105  East  Twenty-second 
Street,  Xew  York,  and  "The  Eookery,"  Eoom  616,  Chicago),  and  The 
0 pen-Air  Quarterly   (Concord,  N.  H.). 

The  number  of  lectures  which  should  l)o  delivered  depends,  of  course, 
on  the  size  of  the  communit}^  and  on  the  other  opportunities  for  edu- 
cating the  public.  Thus,  for  example,  owing  to  the  traveling  tubercu- 
losis exhibit  of  last  year  there  were  exceptional  occasions  for  unusual 
activity  on  the  part  of  the  New  York  Committee.  During  one  year 
in  New  York  City  (1906)  there  were  delivered  under  the  auspices 
of  the  Board  of  Education,  Department  of  Public  Lectures,  35  evening 
lectures  to  adults  in  the  various  pul)lic-school  buildings  of  Greater  New 
York ;  and  under  the  auspices  of  the  Tulierculosis  Committee  there  were 
delivered  54  lectures  in  churches,  clubs,  lodges,  settlements,  etc.,  and 
59  before  labor  unions;  280  lectures  were  delivered  to  school  children, 
with  an  attendance  of  105,000.  These  lectures  to  children,  and  many 
delivered  liefore  clubs,  settlements,  and  labor  unions,  were  in  connection 
with  the  traveling  exhibit.  In  view  of  the  fact  that  tuberculosis  is  so 
very  prevalent  among  the  laboring  population,  the  cooperation  of  a 
tuberculosis  committee  with  such  unions  is  particularly  to  be  recom- 
mended, for  it  cannot  help  l)ut  lead  to  good  results.  The  vast  impor- 
tance of  educating  the  children  in  the  prevention  of  tuberculosis  is  self- 
evident  and  needs  no  further  comment.^ 

The  Public  Press  and  Tuberculosis. — The  public  press  is  a  most 
powerful  factor  in  the  dissemination  of  knowledge  concerning  the  pre- 
vention of  tuberculosis.     However,  to  avoid  sensational  and  inaccurate 

>  An  interesting  and  novel  method  of  educating  the  public  visiting  a  tuberculosis 
exhibition  was  inaugurated  by  the  New  York  State  Department  of  Health.  A 
large  phonograph  for  which  a  well-trained  voice  had  given  a  record  embodying  a 
short,  concise  and  comprehensive  popular  lecture,  was  put  in  motion  at  certain 
intervals.  The  people  usually  gathered  around  and  listened  attentively  to  what 
the  phonograph  had  to  say. 


TUBERCULOSIS   EXHIBITS,   ETC.  425 

accounts  or  misrepresentations  of  what  the  lecturer  lias  said,  it  is  ad- 
visable to  have  a  statement  carefully  prepared  for  the  press  to  be  given 
to  the  reporters  who  may  be  present  at  the  lecture. 

Next  to  the  press  the  clergy  can  certainly  do  much  to  help  the  medi- 
cal profession  in  the  crusade  against  tuberculosis.  The  clergymen  of 
all  denominations  should  see  to  it  that  their  churches  are  hygienically 
constructed  and  well  ventilated.  Fixed  carpets  should  not  be  used 
in  places  of  Avorship  where  so  many  people  congregate.  Catholic  priests 
in  charge  of  large  congregations  may  do  well  to  follow  the  example  of 
a  great  Koman  divine,  the  Bishop  of  Fano,  in  Italy.  In  a  circular  re- 
cently issued  Ijy  him,  he  asks  the  priests  of  his  diocese  to  comply  with 
the  following  rules: 

(1)  In  every  church  the  floors  must  be  regularly  cleaned  with  sawdust, 
saturated  with  a  strong  sublimate  solution.  This  thorough  cleaning  should 
take  place  particularly  after  holidays  when  great  masses  of  people  have 
visited  the  church. 

(2)  Every  week  all  ordinary  chairs  and  confessional  chairs  must  be  thor- 
oughly cleaned  with  moist  rags. 

(3)  The  grate  of  the  confessional  chairs  must  be  washed  every  week  with 
lye  and  then  polished. 

It  might  he  of  advantage  if  such  articles  of  adoration  as  crosses, 
statues,  or,  as  in  Greek  churches,  pictures  which  are  often  kissed  by 
devout  people,  be  included  in  the  periodical  disinfection.  Kissing  the 
Bible  when  taking  an  oath  should  be  discouraged  by  jurists  and  divines. 

Some  ministers  may  not  feel  that  they  have  either  the  knowledge, 
the  ability,  or  the  inclination  to  deliver  a  lecture  or  sermon  on  the  pre- 
vention of  tuberculosis.  In  such  a  case  they  will  do  well  occasionally 
to  invite  a  physician  to  occupy  the  pulpit,  as  was  done  recently  in 
Rochester,  X.  Y.,  to  preach  a  dignified  sermon  which  will  arouse  the 
I^eople  to  an  interest  in  the  antituberculosis  crusade  and  help  them  to 
see  their  duty  toward  the  poor  consumptive  who  is  their  fellow  man. 

Tuberculosis  Exhibits,  etc. — Tuberculosis  exhibits  are  most  impor- 
tant factors  in  the  education  of  the  public  concerning  this  disease.  They 
should  be  objective  presentations  of  the  history,  distribution,  varieties, 
causes,  cost,  prevention,  and  cure  of  tuberculosis.  This  means  models, 
photographs,  charts,  diagrams,  circulars,  etc.,  whereby  hygienic  and  un- 
hygienic methods  of  living,  proper  and  improper  care  of  consumptives, 
are  graphically  shoAvn.  Besides  the  evening  lecture,  which  should  always 
be  a  feature  of  a  tuberculosis  exhibition,  there  should  be  a  person  in 
constant  attendance,  able  to  explain  and  give  information  to  the  visitors. 
Children  from  ten  years  upward  should  be  given  admittance  to  the 
exposition  as  well  as  adults.  The  accom])anying  illustrations  of  parts 
29 


426    PUBLIC  MEASURES  IN  THE   PROPHYLAXIS  OF  TUBERCULOSIS 

of  the  exhibits  of  the  last  International  Congress  ('08)  (see  Figs.  128 
to  130)  give  a  good  idea  of  the  apjjearance  of  such  an  exhibition.  This 
exhibit  was  shown  in  New  York. 

To  show  the  composition,  scope,  and  result  of  such  a  traveling  ex- 
hibit, the  writer  may  be  permitted  to  quote  from  the  above-mentioned 
report,  sul)mitted  l)y  the  secretary,  Mr.  Paul  Kennaday : 

The  effectiveness  of  the  tuberculosis  exhibition  has  been  in  the  nature 
of  a  discovery.  This  has  been  so  with  others,  who  in  many  widely  scat- 
tered parts  of  the  country  have  shown  the  exhibition  of  the  National  Asso- 
ciation, and  most  assuredly  has  it  been  true  in  New  York  City.     It  seems 


Fig.  128. — Exhibition  of  International  Tuberculosis  Congress,    1908. 
(Transferred  to  New  York.) 

more  than  probable  that  it  is  a  plan  of  operation  that  has  come  to  stay  and 
to  spread;  it  may,  therefore,  serve  a  useful  purpose,  if  there  is  here  given 
some  detailed  account  of  the  manner  in  which  these  Committee  exhibitions 
were  handled. 

The  Committee's  Traveling  Tuberculosis  Exhibition  is  made  up  of 
249  frames  of  photographs,  charts,  etc.,  13  models,  and  10  pathologic 
specimens,  all  divided  into  three  classes,  as  shown  more  particularly  by  the 
four-page  programmes  which  are  liberally  distributed  at  all  the  exhibition 
halls.  The  first  division  reads,  "  Tuberculosis  is  a  preventable  disease," 
and  here  are  the  principal  part  of  the  Board  of  Health  exhibits:  A  large 
chart  showing  the  reduction  of  the  death-rate  from  tuberculosis  in  New 
York  City  from  4.92  in  1881  to  2.66  in  1905,  a  series  of  printed  instructions 
for  consumptives  and  those  living  with  them,  and  diagrams  and  photographs 
illustrating  generally  the  educational  and  preventive  work  carried  on  by 


TUBERCULOSIS  EXHIBITS,   ETC. 


427 


the  department.    The  work  of  the  National  Consumers'  League,  of  the  City 
Tenement  House  Department,  the  State  Factory  Department,  and  of  the 


Fig.  129. — Exhieitiox  of  International  Tuberculosis  Congress,  1908. 

Tenement  House  Committee  and  the  Committee  on  the  Prevention  of 
Tuberculosis  of  the  Charity  Organization  Society,  are  shown  here  by  mod- 
els, photographs,  diagrams,  etc. 


Fig.  130. — Exhibition  of  International  Tuberculosis  Congress,  1908. 


Perhaps  most   striking  of  the  exhibits   in  this  section,   if  not   in  the 
whole  exhibition,  are  the  full-size  models  of  a  dark  interior  bedroom,  dirty 


428    PUBLIC  MEASURES  IN  THE   PROPHYLAXIS  OF  TUBERCULOSIS 

and  crowded  with  furniture,  typical  of  the  rooms  in  which  many  a  poor 
man  develops  tuberculosis,  and  the  adjoining  front  room  with  open  win- 
dows and  clean  cot,  spread  with  blankets  between  w^hich  have  been  sewed 
newspapers  as  a  cheap  and  at  the  same  time  warm  covering,  representing 
the  changes  wrought  by  visiting  nurses  and  charity  visitors. 

Under  the  second  division,  "  Tuberculosis  is  a  communicable  disease," 
is  a  collection  of  nine  human  lungs,  presenting  the  healthy  lung,  the  nor- 
mal city  lung  pretty  Avell  spotted  with  dust  and  dirt,  and  lungs  showing 
the  process  of  healing  and  in  A^arious  stages  of  disease.  As  a  part  of 
the  pathologic  exhibit,  and  placed  around  these  specimens  of  lungs,  are 
the  Board  of  Health  signs  prohibiting  spitting,  diagrams  and  photographs 
illustrating  the  methods  of  infection  through  spitting  and  coughing,  and 
an  exhibit  of  dry  brooms,  feather  dusters,  wet  paper,  moist  sawdust,  etc., 
illustrating  the  right  and  wrong  way  to  sw^eep  and  clean.  To  still  further 
enforce  the  practical  value  of  this  division  of  the  exhibition,  there  are  dis- 
tributed at  this  point  simple  instructions  in  relation  to  sweeping  and  dust- 
ing, printed  on  small  cardboards  in  English  on  one  side  and  on  the  reVerse 
side  in  Yiddish,  Italian,  German,  and  Bohemian. 

The  third  and  last  division  of  the  exhibits  is,  "  Tuberculosis  is  a  curable 
disease,"  under  which  comes  the  illustration  by  means  of  photographs  and 
models  of  the  work  of  all  of  the  city  tuberculosis  hospitals  and  special 
tuberculosis  dispensaries.  Here,  in  the  same  way,  are  shown  models 
of  the  Sea  Breeze  Hosjiital  for  Children,  of  the  lean-tos  from  Loomis 
Sanatorium,  of  the  White  Haven  shacks,  and  photographs  from  the  Adiron- 
dack Cottage  Sanatorium,  from  the  Boston  Day  Camp,  and  from  a  num- 
ber of  other  places  outside  of  New  Y'^ork  City.  The  exhibits  are  all  labeled, 
and  throughout  there  is  the  attempt  to  make  the  lesson  so  plain  that  it 
will  be  readily  understood  by  all,  while  lectures  and  demonstrations  alike  try 
to  translate  for  the  practical  application  of  the  average  man  \;he  graphic 
representation  of  tuberculosis,  preventable,  communicable,  and  curable. 

With  the  amount  of  material  that  is  shown,  ease  and  rapidity  of  instal- 
lation is  all  important,  and,  therefore,  models,  picture  frames,  and  cases  are 
all  so  made  that  they  may  be  handled  with  the  least  possible  delay  and 
without  unnecessary  labor.  For  the  setting  up  of  the  exhibits,  taking  from 
two  to  three  days,  is  but  a  small  part  of  the  work  necessary  in  connection 
with  each  exhibition.  After  the  arrangement  of  the  definite  preliminary 
itinerary,  the  substitution  of  other  exhibition  places  for  those  which  have 
dropped  out,  and  perhaps  the  complete  rearrangement  of  the  whole  sched- 
ule, it  is  time  to  hold  a  series  of  conferences,  about  a  month  in  advance 
of  each  exhibition,  when  the  cooperation  is  sought  of  the  local  physicians, 
settlement  workers,  school  teachers,  clergymen,  and  generally  all  those  who 
are  identified  with  the  social  work  of  the  particular  neighborhood  in  which 
the  exhibition  is  to  be  held;  after  this,  a  schedule  is  arranged  for  the 
attendance  from  ten  o'clock  in  the  morning  until  ten  o'clock  in  the  even- 
ing of  persons  competent  to  explain,  in  turn,  to  small  groups  of  people  the 
meaning  of  the  different  exhibits  and  the  purpose  of  the  exhibition — phy- 
sicians and  nurses  are  usually  asked  to  do  this  part  of  the  work,  those 


TUBERCULOSIS  EXHIBITS,   ETC.  429 

from  the  region  in  which  the  exhibition  is  to  be  held  being  called  on  as  far 
as  possible,  each  member  of  the  group  selected  for  demonstration  for  each 
exhibition  being  asked  to  volunteer  for  three  periods  of  two  hours  each. 
The  Board  of  Health,  realizing  the  large  possibilities  of  these  exhibitions, 
ih  addition  to  loaning  much  exhibition  material  and  department  wagons 
for  moving  the  exhibition  from  place  to  place,  regularly  assigned  two  phy- 
sicians for  the  daily  instruction  of  the  school  children,  and  thus  the  task 
was  much  lightened  of  obtaining  volunteer  instructors  in  sufficient  number 
to  be  on  hand  eight  and  more  hours  a  day  for  an  almost  unbroken  period  of 
five  months. 

On  the  whole,  the  attendance  at  these  exhibitions  has  been  most  satis- 
factory, running  from  about  3,000  in  the  smaller  halls  to  49,000  in  three 
weeks  at  the  Educational  Alliance,  a  large  Hebrew  educational  and  social 
betterment  institution  in  the  congested  lower  East  side  of  the  city.  In  five 
months  there  has  been  a  total  attendance  of  over  82,000  persons. 

The  most  promising  single  feature  of  the  scheme  has  been  the  intelli- 
gent interest  shown  by  the  children  of  twelve  years  of  age  and  upward  who, 
under  arrangement  with  the  Department  of  Education,  have  been  sent  to 
the  exhibitions  in  charge  of  their  teachers  by  their  local  principals  as  a 
regular  part  of  their  school  work.  For  the  instruction  of  these  chil- 
dren the  Department  of  Health  has  regularly  assigned  a  Department 
Inspector,  Dr.  Anna  C.  Judkins,  who  in  a  plain,  simple,  and  practical 
manner  explained  the  exhibits  to  the  children  and  answered  their  many 
questions. 

While  speaking  of  tuberculosis  exhibitions,  it  is  but  right  to  mention 
one  of  the  latest  features  in  the  line  of  pictorial  demonstrations  of  value 
in  the  antituberculosis  crusade — the  open-air  lantern  exhibit,  Avhich 
originated  with  Dr.  Oscar  H.  Rogers,  of  Yonkers.  The  New  York 
Health  Department  made  immediate  use  of  Dr.  Eogers's  admirable  sug- 
gestions. Thus,  during  last  summer,  in  twenty-five  of  the  small  parks 
of  the  city,  and  at  five  recreation  piers  on  the  river  fronts,  there  were 
shown,  before  crowds  varying  in  numbers  from  several  hundred  to  two 
or  three  thousand,  a  set  of  stereopticon  slides  giving  in  short  sentences 
easily  understood  advice  in  relation  to  tuberculosis.  Along  with  these 
sentences  pictures  were  thrown  on  the  screen  which  showed  the  wa3's 
in  which  the  bacilli  causing  tuberculosis  are  transmitted  by  the  cough 
and  expectoration  of  those  who  have  it,  by  dust  and  air  filled  with 
particles  of  dried  sputum.  They  showed  the  effect  of  the  disease  on  the 
lungs;  how  overcrowded,  dirty,  badly  ventilated  rooms  and  tenements 
cause  and  spi-ead  il  ;  liow  llu'se  conditions  are  being  remedied  ])y  new 
building  laws;  how  the  DepariiiKMit  of  Health  renovates  rooms  infeeled 
with  the  germs  of  consuinplion  by  fumigation  and  the  removal  and  dis- 
infection of  bedding  and  fiiniisliings ;  how  it  cares  f<n"  patients  in  the 
Kiverside  Hospital;  and  finally  the  possibility  of  arresting  and  curing 


430    PUBLIC  MEASURES   IN  THE   PROPHYLAXIS   OF   TUBERCULOSIS 

many  cases  in  country  sanatoria,  such  as  that  recently  opened  by  the 
Department  at  Otisville,  Orange  County,  N.  Y. 

In  Dr.  Eogers's  excellent  paper,  "  A  Working  Programme  for  a 
Small  City/'  read  at  the  third  annual  meeting  of  the  Xational  Asso- 
ciation at  Washington  (1907),  he  gives  a  list  of  illustrations  of  which 
he  made  use  in  his  public  propaganda  with  the  open-air  lantern  exhibit. 
They  comprise  twent3^-one  graphic  illustrations  suitable  for  any  city, 
and  were  shown  in  the  following  order : 

1.  Plan  of  a  street  in  Yonkers  showing  infected  houses  (similar  to 
the  "  Lung  Block "  sketched  in  the  "  Handbook  on  the  Prevention  of 
Tuberculosis  ")• 

2.  Plan  of  another  street  in  a  different  part  of  the  city. 

3.  A  graphic  illustration  of  the  mortality  among  people  of 'various 
nationalities. 

4.  A  graphic  illustration  of  the  mortality  in  various  occupations. 

5.  A  photograph  of  tubercle  bacilli. 

6.  Section  of  normal  lung  showing  air  vesicles. 

7.  Section  of  diseased  lung  showing  tubercles. 

8.  A  crude  sketch  showing  infection  through  spitting.  This  effective 
drawing  was  borrowed  from  the  tuberculosis  exhibit  and  is  one  of  the 
strongest  arguments  so  far  devised.  In  our  lectures  we  speak  of  the 
spitter  as  the  "  murderer." 

9.  The  same  sketch  showing  infection  through  coughing.  This  came 
from  the  same  source. 

10.  Photograph  of  a  gelatin  plate  infected  by  a  fly  which  had  just 
been  walking  in  tuberculous  spit. 

11.  A  gelatin  plate  infected  by  tubercles  expelled  by  a  tuberculous 
patient  in  the  act  of  coughing. 

12.  Photographs  of  various  spitcups. 

13.  Dark,  close  room  in  tenement,  showing  lounge  on  which  a  con- 
sumptive lay  dying. 

14.  Same  tenement,  with  lounge  near  an  open  window  and  arranged 
by  visiting  nurse — an  effective  illustration  of  the  value  of  the  visiting 
nurse. 

15  and  16.     Home  treatment  on  fire  escape. 

17.  Home  treatment  on  roof  of  tenement  house. 

18.  Window  tent  for  use  in  home  treatment. 

19.  Shack  treatment  as  carried  on  at  Liberty,  N.  Y. 

20.  Shack  treatment  as  carried  on  at  Ward's  Island. 

21.  Model  of  inexpensive  shack. 

As  a  further  help  to  those  Avho  wish  to  follow  this  method  of  reach- 
ing people  with  the  antituberculosis  propaganda,  Mr.  Kennaday,  in  his 
admirable  report,  gives  in  full  the  sentences  that  have  been  used  with 
success,  with  the  perhaps  obvious  warning  that  in  preparing  slides  for 


TUBERCULOSIS  EXHIBITS,   ETC.  431 

this  purpose  the  shorter  the  sentences  the  better,  and  that  the  letters 
should  be  large,  heavy,  and  thick,  so  as  to  be  easily  legible  at  some  dis- 
tance on  an  eighteen-foot  screen,  a  size  that  has  been  found  serviceable. 
These  sentences  will  be  found  reproduced  in  the  Appendix. 

As  a  novel  means  to  bring  the  gospel  of  the  prevention  of  tubercu- 
losis to  the  masses,  and  particularly  to  the  workers  in  great  factories, 
we  must  not  fail  to  mention  the  following  ingenious  method :  An  itin- 
erant tuberculosis  exposition  was  recently  organized  under  the  auspices 
of  the  Kensington  Tuberculosis  Dispensary  of  Philadelphia  and  the 
Kensington  branch  of  the  Y.  M.  C.  A.  During  the  noon  hour  a  course 
of  lectures  was  delivered  to  the  mill  workers  in  the  northeastern  district 
of  Philadelphia  from  a  wagon  fitted  with  a  suitable  exhibit  to  illustrate 
the  points  made  by  the  speakers. 

Books  and  popular  essays,  pamphlets  and  circulars,  intended  to  en- 
lighten the  public  on  the  subject  of  tuberculosis  should  be  concise,  avoid- 
ing technicalities  and  scientific  phrases.  An  attempt  to  incorjjorate  all 
these  essentials  in  compact  form  has  been  made  by  the  writer  in  a  little 
essay  entitled  "  Tuberculosis  as  a  Disease  of  the  Masses  and  How  to 
Combat  it"  (Knopf,  '07).  But  for  large  and  general  distribution  such 
a  pamphlet,  for  example,  as  that  issued  by  the  New  York  City  Health 
Department  is  perhaps  best  fitted  for  the  purpose  (see  Appendix). 

If  the  population  for  which  the  circulars  are  intended  is  presumably 
not  able  to  read  English,  it  is  of  course  essential  that  the  example  of 
the  New  York  Health  Department  should  be  followed,  which  has  its 
popular  circulars  translated  into  such  languages  as  Bohemian,  Chinese, 
German,  Hebrew,  Hungarian,  Italian,  Polish,  Euthenian,  Russian,  etc. 
To  encourage  the  foreign  population  within  the  borders  of  the  United 
States  to  study  the  health  regulations  in  the  language  of  their  adopted 
country,  it  may  also  be  well  to  follow  the  example  of  the  New  York 
Health  Department  and  print  the  circular  in  English  on  one  side  of 
the  page  and  in  the  language  of  a  respective  foreign  country  on  the 
other, 

A  school  circular,  or  catechism,  which  was  recently  issued  by  the 
New  York  Board  of  Health,  may  also  serve  as  a  model  for  educating 
the  rising  population  in  the  simple  methods  of  the  prevention  of  tuber- 
culosis. Of  this  catechism  about  700,000  copies  have  been  printed  and 
d'  tributed  for  the  use  of  school  children  throughout  all  the  public 
schools  of  the  city  of  New  York.  A  small  leaflet  taken  from  the  chapter 
on  "  School  Hygiene  "  in  the  essay  referred  to  may,  perhaps,  also  be 
helpful  as  the  A  B  C  in  the  education  of  younger  children. 

A  valuable  pamphlet  on  "  The  Opportunity  and  the  Responsibility  of 
the  Teacher  in  the  Prevention   of  Tuberculosis "  has  been  issued  by  the 


432    PUBLIC   MEASURES   IN  THE   PROPHYLAXIS  OF   TUBERCULOSIS 

Tuberculosis  Committee  of  the  Charity  Organization  Society,  having  the 
following  subtitles:  The  Cause  of  Tuberculosis;  The  Germ  of  Tubercu- 
losis; What  Protects  Against  Inhaled  Germs;  The  Development  of  the 
Tubercle  Bacillus ;  Tuberculosis  is  Not  a  Contagious  Disease ;  Tuberculosis 
is  Not  Inherited;   The  Methods  of  Prevention;  Spitting;  Cleaning;  The 


Don't  Gire  Consampiion  to  Others 

oi'Miiiiplioii   in  ''a(i9>-<l    by  ^rreS  tliechar^)^    (roiu    tbc  Iut  g; 


Oont  Spil  on  Co'.rtormiiewalL'.    Co- 
ir Yoa  Have  A  Slcaily,  BronchiBl  Cold 

peDT.ty      Don't  Take  Patent 
Frrsh  Air,  r>ODd  Food  and  Re 
KEEP  YOUR 


.  k)  •  ioeU-T  or  t  Altfvttj     lUnmber 
ABLE  diMAM  ud  lh«  <nTf  for  ri  a  tnsh  sir,  ntt  and  gioi  fegd. 

Don't  Give  II  to  Otlicf  People 

f«^  ttirei^gh  SPITTIPiO.     P^Dt  iplt  CD  Itw 

dkcrthMf.  or.  twttor  yit  it\U)  i  r'oth  wbirb  c«0  b«  bart»d. 

Tbe  Coinmlllee  on  Ihe  PrcTenlton  o(  Tuberculosis 

CdlMaTY  ORr.ANIXATION  SOCIETY 
(I>y  Cotan«y  ot  Siege!  Cooper  Co.) 


^^fi".^j;,;'cs.  I 


Fig.  131. — An  Effective  and  Inexpensive  Method  of  Tuberculosis  Propa- 
ganda. Free  advertisements  of  New  York  Tuberculosis  Committee  on  back 
of  street-car  transfers. 

Duty  of  Consumptives;  Tuberculosis  is  Curable;  Administrative  Con- 
trol; The  Department  of  Health;  The  Department  of  Public  Charities; 
Bellevue  and  Allied  Hospitals;  The  Tenement  House  Department;  Other 
Administrative  Activities;  Dispensaries;  Sanatoria  and  Other  Private 
Agencies. 


In  order  that  the  patient  may  choose  for  his  dispensary  the  insti- 
tution nearest  his  home,  a  map  of  the  Manhattan  districts,  with  Eoman 


TUBERCULOSIS   CLINIC  435 

letters  showing  ti:e  locality  of  the  dispensaries  and  hours  when  they 
are  open,  is  reprodii.^ed  on  the  last  page  of  these  circulars. 

A  unique  way  of  s;ireading  the  knowledge  concerning  the  prevention 
of  tuberculosis  is  to  utjjze  the  back  of  street-car  transfers  (see  Fisr. 
131).  .; 

Circulars  of  information  may  have  to  be  varied  to  suit  the  locality 
in  which  they  are  to  be  distributed,  and  the  people  to  whom  they  are 
to  serve  as  guides,  and  the  circulars  and  leaflets  given  in  the  Appendix 
are  by  no  means  expected  to  suit  all  purposes,  all  classes,  nor  all  com- 
munities. 

From  a  circular  intended  for  physicians  only,  which  was  recently 
issued  by  the  ISTew  York  City  Health  Department  on  the  subject  of 
bacteriologic  examination  of  sputum,  are  quoted  the  following  conclu- 
sions which  may  prove  helpful  in  the  crusade  as  far  as  the  profession 
is  concerned : 

First.     Incipient  tuberculosis  tends  to  recovery. 

Second.  Advanced  tuberculosis,  with  or  without  mixed  infection,  tends 
to  a  fatal  issue. 

Third.  In  all  coughs  which  last  more  than  a  few  weeks,  and  which 
are  not  associated  with  asthma,  emphysema,  or  cardiac  disease,  tubercu- 
losis is  to  be  suspected  as  a  cause. 

Fourth.  Successful  treatment  and  prophylaxis  demand  the  earliest 
possible  diagnosis. 

Fifth.  The  diagnosis  of  incipient  pulmonary  tuberculosis,  properly  so 
called,  is  made  positive  when  tubercle  bacilli  are  found  in  the  expec- 
toration. 

Sixth.  Repeated  examinations  of  the  expectoration  are  frequently 
necessary  to  demonstrate  the  presence  of  the  tubercle  bacilli  in  incipient 
cases  of  pulmonary  tuberculosis. 

In  order  that  bacteriological  examinations  of  the  sputa  may  be  at  the 
service  of  the  physicians  in  all  cases,  the  Health  Department  is  prepared 
to  make  such  examinations,  if  samples  of  the  sputa,  freshly  discharged, 
are  furnished  in  clean,  wide-necked,  tightly  stoppered  bottles,  accom- 
panied by  the  name,  age,  sex,  and  address  of  the  patient,  duration  of  the 
disease,  and  the  name  and  address  of  the  attending  physician.^ 

Tuberculosis  Clinic. — In  the  larger  centers  of  population,  in  fact, 
perliaps,  in  all  larger  communities  where  there  are  a  considerable  num- 
ber of  poor  or  relatively  poor  people,  the  tuberculosis  dispensary,  or  at 
least  a  special  tuberculosis  class  in  an  ordinary  dispensary,  is  one  of  the 
most  important  factors  in  the  crusade  against  tuberculosis. 

>  I  have  found  Dr.  Hart's  improved  wooden  box  with  a  dark  iiniiornieable  lining 
the  most  suitable  for  sending  sputum  specimens  to  the  laboratory  for  examination, 
(See  Appendix.) 


434    PUBLIC  MEASURES  IN   THE  PROPHYLAXIS  OF   TT„^^^,.^  „„_„ 

'The  object  and  purpose  of  a  tuberculosis  clinic,  as  it/      ,  ,  p    ,, 

in  the  first  report  of  the  Clinic  for  Pulmonary  Disf^       ^^  ^j      jjg^ith 
Department  of  the  City  of  New  York,  may  be  set  r,^j^  ^^  follows : 

It  was  early  recognized  that  the  establishme;^  ^^  ^  municipal  clinic 
or  dispensary  would  be  of  great  assistance  in  ;^^  attainment  of  the  fol- 
lowing  desired  objects : 

l.The  Early  Recognition  and  Accuv^^^  Diagnosis  of  Pulmonary 
Tuherculosis.-It  is  now  generally  admitt^'^  ^^^^  tuberculosis  is  frequently 
a  curable  disease,  and  that  incipient  tr^^^^^j^^.^^  ^^^^^  favorable  condi- 
tions, tends  to  recovery;  but  to  msi^^^  ^^^^  ^.^^^^^^^  ^^^^  diagnosis  must 
be  made  at  the  earliest  possible  mo^^^^^     ^^^  ^^^^  ^^^^^^  ^^^^^^^  ^^^^_ 

ical  examinations  be  made,  togey-         .,,  ,    ,         ,  •     +•     ^ 

.  ^     Aier  with  repeated  sputum  examinations, 

as  required  in  connection  with/,       t    ••  i  i,-  4.         -u  t-  ■        i  r  +  - ^1,^^ 

^  -/the  clinical  history,  but  m  addition,  when 

necessary,  the  tuberculin  test, /S       ^  ■     ^-  j      j-       „  i,„ 

,,/'         ,        ,  .    /±loentgen-ray  examinations,  and  radiography 

should  be  employed  to  assisj.  .   .         ,  ,  ■,  ,    ■,•        ^^. 

^       .  2  m  arriving  at  an  early  and  correct  diagnosis. 

■  .  .         Ill-         ypervision    of   Patients   under   Treatment. — This 

,  '  .  -ide  not  only  hygienic  and  medical  treatment,  but 

also    the    furnishing  /j.      ■       ^  j?    •   r  ^-         •  •  i  „   „^ 

/T?      r  1,     n  yof    circulars    of    mtormation    111    various    languages 

(English,  ^erman,^^.^^.^j^^    Italian,    Chinese,   Ruthenian,   Polish,   Hun- 

^  '  lAi)'  containing  information  as  to  the  nature  of  the  dis- 

ease, and  carefuj- .     ^^.  ,xi  x-  u.     -u    ^.  ^ 

A  instructions  as  to  the  precautions  necessary  to  be  taken 

./  infection  of  others.     Paper  sputum  cups,  paper  handker- 

'  proper  food   (milk  and  eggs)   should  be  supplied  to  indigent 

.  and  needy, 

3  ta'''^'^': 

■  'e  Continued  Observation  of  the  Homes  of  Indigent,  Needy,  and 
.  tint  Cases,  Including  all  those  Discharged  from  the  Public  Insti- 
yns  of  the   City. — A   special  staff  of  trained  nurses  should  visit  the 

,/ients  at  their  homes  to  see  that  the  instructions  given  are  observed, 

.hat  the  sanitary  surroundings  are  satisfactory,  and  to  afford  such  assist- 

y^ance   as    is   required.      Suitable   cases   should   be   referred   to   the   various 

/     charitable  organizations  for  food,  fuel,  ice,  etc.     Special  attention  should 

f        be  paid  to  the  children  in  the  families  of  tuberculous  persons,  and  every 

effort  made  to  prevent  their  infection. 

4.  The  Removal  of  Cases  Requiring  such  Care  to  Hospitals  or  Sana- 
toria.— These  cases  fall  under  four  heads :  (a)  Advanced  or  bedridden 
consumptives,  with  profuse  expectoration,  who  will  not  or  cannot  take 
the  necessary  precautions  against  spreading  the  disease,  and  whose  pres- 
ence at  home  is  a  menace  to  others  in  the  family;  (b)  consumptives  who 
are  able  to  get  about,  but  who  are  unable  to  Avork  and  are  entirely  depend- 
ent upon  their  earnings  for  their  livelihood;  (c)  incipient  cases,  who  stand 
a  good  chance  of  recovery  if  removed  to  sanatoria  outside  of  the  city; 
(d)  consumptives  living  in  lodging  houses  and  those  having  no  home. 

5.  The  Provision  of  a  Municipal  Institution  to  lohich  Cases  of  Tuber- 
culosis may  be  Referred. — (a)  By  physicians  (indigent  patients,  etc.) ; 
(6)  by  institutions  (on  the  discharge  of  consumptive  patients  from  hos- 
pitals or  sanatoria) ;  (c)  by  the  various  charitable  organizations  through- 


TUBERCULOSIS  CLINIC 


435 


out  the  city  which  keep  tuberculous  cases  under  observation;  (d)  by  other 
persons  doing  individual  charitable  work  who  may  come  in  contact  with 
such  persons;  and   (e)  by  other  city  departments. 

6.  The  Extension  and  Strengthening  of  the  Sanitary  Control  of  Tuber- 
culosis among  the  Poor  by  the  Department  of  Health. 

7.  The  Care  of  Laryngeal  Cases. — The  involvement  of  the  larynx  is 
one  of  the  saddest  complications  of  pulmonary  tuberculosis,  and  the  pain, 
distress,  and  discomfort  of  the  patients  are  great.  While  the  prognosis 
in  these  cases  is  extremely  grave,  yet  under  proper  treatment  recovery 
takes  place  in  some  instances,  and  in  most  the  distress  of  the  patient  can, 
in  some  degree  at  least,  be  relieved.  Special  attention  should  be  paid  to 
such  cases  in  a  fully  equipped  throat  clinic. 


In  a  city  like  New  York,  where  ground  is  expensive,  it  is  often  dif- 
ficult to  procure  the  desired  plot  for  the  erection  of  a  municipal  build- 
ing, particularly  for  the  purpose  of  treating  tuberculosis.  One  has, 
then,  to  contend  with  the  objection  of  neighbors  gviided  by  selfish  mo- 
tives, by  phthisiophobia,  fear  of  depreciation  of  value  of  neighboring 
property,  etc.  The  ideal  dispensary  should  be  placed  on  elevated  ground, 
in  a  locality  where  there  is  relatively  little  traffic,  yet  easy  of  access, 
and  where  the  air  is  as  pure  as  can  be  found  M'ithin  the  city  limits. 
Xot  all  such  ideal  conditions  existed  when  the  Xew  York  Health  De- 
partment decided,  in  1903,  to  establish  its  first  municipal  tuberculosis 
dispensary.  For  obvious  reasons, 
the  name  "  Clinic  for  Communica- 
ble Pulmonary  Diseases  "  was  de- 
cided on.  The  lot  being  narrow  and 
between  high  structures,  and  all  the 
available  ground  space  being  re- 
quired, windows  could  only  ])e  had 
on  the  ends.  The  building  (Fig. 
132)  was  therefore  limited  in  heiglit 
to  one  story,  with  a  cellar  below, 
in  order  that  each  room  could  be 
lighted  by  a  ventilating  skylight. 
To  insure  further  ventilation,  square 
openings  were  cut  high  up  in  the  walls  of  the  various  rooms,  connecting 
them  witli  each  other  and  with  tlie  halls,  and  electric  fans  were  installed 
in  suitable  places. 

As  will  be  seen  in  the  plan  (Fig.  133),  the  subdivisions  are  as  fol- 
lows: (1)  Entrance;  (2)  registration  room  in  which  all  applicants  are 
received,  their  history  taken,  and  all  records  filed;  (3  and  4)  waiting 
rooms  for  male  and  female  patients,  each  with  its  toilet;  (5  and  6)  dress- 
ing rooms  for  physicians  and  nurses,  each  containing  a  closet  for  cloths, 


Fig.  132. — Exterior  of  Tuberculo- 
sis Clinic  of  New  York  Health 
Department  at  965  Sixth  Avenue. 


436    PUBLIC   MEASURES  IN  THE   PROPHYLAXIS  OF   TUBERCULOSIS 


a  washstand,  and  toilet;  (7)  throat  clinic,  with  complete  outfit,  includ- 
ing compressed-air-spray  apparatus,  electric  sterilizer  for  instruments, 
instrument  cabinet,  and  a  full  stock  of  all  necessary  instruments  and 

apparatus;  (8)  Eoentgen-ray 
room,  the  equipment  of  which 
consists  of  a  twelve-inch  coil, 
with  electrolytic  breaks  and  mi- 
crorheostatic  control,  Crooke's 
tubes  of  several  patterns  and 
sizes,  fluoroscopes  (15  X  18 
inches),  tube  stands,  examina- 
tion table,  supply  and  appara- 
tus cabinet,  etc.;  (a  dark  room 
for  the  immediate  development 
of  radiographic  plates  is  being 
constructed  in  the  basement  of 
the  clinic,  beneath  the  X-ray 
room)  ;  (9  and  10,  11  and  12) 
nuile  and  female  examination 
and  patients'  dressing  rooms, 
containing  desks,  stools,  etc., 
also  a  pneumatic  cabinet  for 
compressed-  or  rarefied-air 
treatment;  and  (13)  drug  room, 
containing  in  enameled  metal 
cabinets  a  full  supply  of  all 
medicines  furnished  by  the  drug 
laboratory  of  the  Department  of 
Health.  The  floors  are  of  ce- 
ment, and  all  corners  and  angles 
are  rounded  to  prevent  accumu- 
lation of  dust  and  dirt;  all  fur- 
niture is  enameled  metal.  In 
the  basement  lockers  are  placed 
for  physicians'  and  attendants' 
gowns,  individual  stethoscopes, 
etc.  The  supplies  (blanks,  cir- 
culars, cards,  etc.)  of  the  clinic 
are  also  stored  there. 

Large  signs  indicating  that 
spitting  on  the  sidewalk  is  pro- 
hibited are  placed  at  the  en- 
trance door  of  the  clinic,  and 


TUBERCULOSIS  CLINIC  437 

the  following  signboard   (Fig.  134)  in  four  languages  greets  the  patient 
on  his  arrival  in  the  waiting  room : 


Donor  spit  on  the  floorbr  in  ^nythin^  except  the  brown  pap^r " 

envelope  furnistied  for  thepiOrpose.  When  you  cough. hMitet^^ 

piece  of  musfin  given  to  voii  bj^fore  your  inouih.Use  the  rausltf^ 

aiso  for  wiping  the  nfiouth  dlrijvose  afterispitting  w.^ 

;:;3Tie^^t1n^.  Men  are  forbidden  to  smoke  or  wear- 

i^fl^eir  hats  while  ifl  the  cihic.  '  :; 


f%-- 


h 

•'^'^5  iet i>erbotcn  cwf  ben  ^o0tn gu sp(jcrcn:fopiirfen  Gte  in  Ckis 
A  braunr^Pcj^icr(£om>ert  h>dcfe©ie  Jbeim^Eintritl  crNten  ^Hhtu)  ' 
I iSe  \mm  ctrr  n i  e  sf n  iKtlte n  (Sie  ba$1[ccisse  WuslmtttclV^' 
»s^l30r  ten57?unO  6onntr>isclbch  (5ic  Vi\xxi^  «uc  9Jqsc  mlt 
tems^eJben  Xutl)  ab.Das  Hciucbcn  istter  ^cr^ei^iif, 
'9;iannermii»»enif)i*e^utealbi;iehmea^^^^^   ;  §§^^'-^^4; 

Hon  sputate  per  terra  nealtrovemaggltaTito  nella  busta  color,  marrorffl 
Che  vi  viene  fornita  a  qoesto  scopo!  Quando  tossite  ten^tevi  davanrffe 
alia  bocea  il  pezzo  dl  m«s$Qlina  cha  vi  yiene  dato  •espres'samenf^ri ' 
"''Jela stessa mussoiinaper aseiugarvj  la boc(^a o  il  naso  dppQ  ' 
f  sputafo  0  starnutato.  E  proibifQ  agli  uomini  di  tenere.II  CappeJIo  , 
;3po  e  di  fumare  quando  vefenq  alia  clinjca,  /A.iiMTC, ' 


iim     I  I  III 


Fig.  134. — Signboard  for  Dispensary  Waiting  Room. 

The  New  York  Health  Department,  with  the  aid  of  the  Dispensary 
Association,  has  undertaken  the  examination  for  tuberculosis  of  all  the 
children  of  parents  who  frequent  the  tuberculosis  clinics.  The  work  is 
still  in  progress,  and  thus  far,  strange  to  say,  only  a  relatively  small 
number  of  tuberculous  children  have  been  discovered.  Another  inter- 
esting feature  which  has  recently  been  inaugurated  by  the  Tuberculosis 
Committee  of  the  Charity   Organization  Society  of   New  York   is  the 


438    PUBLIC   MEASURES   IN   THE    PROPHYLAXIS   OF   TUBERCULOSIS 

examination  of  certain  professions;  thus,  for  example,  every  individual 
belonging  to  a  certain  printer's  union  has  been  examined  for  tubercu- 
losis. It  must  be  evident  that  through  such  methods  of  examining 
thousands  of  children  and  adults,  where  the  presence  of  tuberculosis 
may  be  suspected,  a  number  of  early  or  incipient  cases  will  surely  be 
discovered  and  a  considerable  number  of  lives  saved. 

In  view  of  the  time  and  care  it  takes  to  examine  individuals  sus- 
pected of  tuberculosis,  and  to  investigate  their  home  environments  and 
social  conditions,  it  is  almost  impossible  to  do  justice  to  all  the  cases 
which  apply  to  the  dispensary  in  a  large  city. 

Advice  and  Care  Stations. — To  supplement  the  work  of  the  dispen- 
sary, there  have  been  recently  established  in  Berlin,  Germany,  a  number 
of  advice  and  care  stations  for  the  tuberculous  ("  Auskunft  und  Fiir- 
sorge  Stellen  fiir  Tuberkulose")  which  do  excellent  work,  both  in  the 
medical  and  social  combat  of  tuberculosis  as  a  disease  of  the  masses. 
In  these  advice  stations  patients  are  not  treated,  but  only  examined  and 
advised  what  to  do  and  where  to  go.  Investigations  of  home  environ- 
ments, social  conditions,  and  the  presence  of  other  tuberculous  members 
in  the  family  are  carefully  made. 

A  very  important  feature  of  these  advice  and  care  stations  is  that 
they  examine  not  only  adults,  but  children  as  well.  Thus,  for  example, 
according  to  the  latest  report  of  Dr.  Kayserling,  the  general  secretary 
of  the  central  committee,  no  less  than  6,924  children,  5,689  women,  and 
3,033  men,  a  total  of  15,646  persons,  were  examined  in  the  five  Berlin 
stations  within  one  year  and  seven  months. 

Dr.  Arnold  C.  Klebs,  who  has  visited  these  stations  and  investigated 
their  work,  says : 

To  my  mind  these  advice  stations  are  of  fundamental  importance  in 
the  fight  against  the  disease,  provided  they  are  similarly  run  to  those 
in  Berlin.  They  are  more  important  than  the  dispensaries  because  they 
have  a  much  wider  radius  of  activity.  In  a  fight  against  a  disease  which 
is  so  closely  dependent  on  social  conditions  the  institution  Avhich  exerts 
a  widespread  influence  is  the  most  important.  Everything  else  has  its  use- 
fulness and  its  importance,  but  viewed  from  the  standpoint  of  the  masses 
and  their  health,  I  put  the  advice  stations  ahead  of  everything. 

The  writer  agrees  with  Dr.  Klebs  that  such  advice  and  care  stations 
might  with  advantage  l)e  established  in  some  of  our  large  American 
cities  which  desire  to  fight  the  white  plague  according  to  the  most 
modern  and  efficient  methods.  It  must  be  evident  that  through  such 
institutions,  combined  with  the  dispensary  work  outlined  above,  the 
proper  cases  for  sanatorium  treatment  can  be  more  easily  selected,  the 
necessary  isolation  of  hopeless  cases  accomplished,  centers  of  infection 


SEASIDE   AND   INLAND   SANATORIA  FOR  CHILDREN  439 

removed,  unsuspected  tuberculous  cases  discovered,  unhygienic  environ- 
ments improved,  and,  last  but  not  least,  the  children  of  tuberculous 
parents  protected  in  time  from  contracting  the  disease. 

The  necessity  for  the  timely  care  of  children  of  tuberculous  parents 
who  may  have  inherited  a  tendency  to  tuberculosis  or  acquired  it 
through  unhygienic  environments,  has  been  demonstrated  in  France  by 
the  admirable  work  known  as  "  L'(Euvre  de  preservation  de  Tenfance 
contre  la  tuberculose,"  inaugurated  by  tlie  late  Professor  Grancher,  of 
Paris. 

This  work,  as  instituted  in  Paris,  consists  in  the  main  in  removing 
the  children  of  poor  tuberculous  parents  from  the  center  of  infection, 
either  to  good  sanitary  private  homes  in  the  country  or  to  seaside  or 
inland  sanatoria.  There  is  no  time  limit;  the  children  may  stay  away 
until,  in  the  opinion  of  the  supervising  physician,  they  are  strong  enough 
to  resist  tuberculous  invasion.  The  removal  of  these  children  is,  of 
course,  always  done  with  the  consent  of  the  parents.  The  first  complete 
report  of  the  work  of  the  society  was  given  out  at  the  recent  tubercu- 
losis congress  at  Paris,  and  showed  most  gratifying  results.  The  sooner 
an  improvement  is  made  in  the  predisposed  child's  unh3'gienic  environ- 
ments, the  greater  are  the  chances  for  ultimately  conquering  his  pre- 
disposition. 

In  placing  children  in  country  homes  the  greatest  care  must,  how- 
ever, be  exercised  to  see  that  the  infants  or  children  do  not  enter  Avorse 
hygienic  conditions  than  they  had  left.  Experience  has  shown  that 
there  are  families  in  the  country  who  make  boarding  such  children  a 
profitable  business  by  confiding  their  care  to  the  invalid  of  the  family 
who  is  not  able  to  do  anything  else.  It  must  be  evident  that  the 
invalid,  if  he  or  she  is  tuberculous,  may  thus  frequently  become  a  source 
of  infection  to  the  little  ones. 

Seaside  and  Inland  Sanatoria  for  Tuberculous  Children. — Children 
with  tuberculous  bone,  joint,  or  scrofulous  lesions  seem  to  do  best  in 
seaside  hospitals  and  seaside  sanatoria.  The  statistics  from  European 
sanatoria,  and  of  Sea  Breeze  Sanatorium  at  Coney  Island,  bear  out  this 
assumption  (Fig.  135).  However,  institutions  of  this  kind  situated  in 
mountainous  regions  and  sometimes  even  in  lowlands  have  also  been 
productive  of  much  good.  As  evidence  of  this  may  be  mentioned  the 
excellent  work  done  by  W.  S.  Halsted  ('05),  of  Johns  Hopkins  Hospital, 
at  Baltimore.  All  such  institutions  must,  of  course,  have  school  facili- 
ties attached  to  them  so  that  the  mental  development  of  the  children 
may  keep  pace  with  their  physical  improvement.  Where  there  are  many 
children  strongly  predisposed  to  pulmonary  tuberculosis  or  afflicted  with 
the  disease,  special  schools  have  been  suggested.  Outdoor  instruction, 
whenever  possible,  should  be  the  main  feature  of  these  schools. 


440    PUBLIC   MEASURES  IN  THE  PROPHYLAXIS  OF   TUBERCULOSIS 

Such  a  fresh-air  school  has  recently  been  established  in  Providence, 
E.  I.  It  was  formally  opened  on  January  27,  1908.  The  school  is  con- 
ducted indoors,  with  great  swinging  windows  on  three  sides  of  each 
room,  besides  which  an  extensive  system  of  ventilation  affords  an  abun- 


FiG.  135. — Open-air  Treatment  of  Surgical  Tuberculosis  at  Sea   Breeze 
Coney  Island.     Spine  cases  treated  with  modified  Bradford  frame. 

dance  of  cold,  pure  air,  fiee  from  germs.  The  idea  of  establishing  the 
school  was  first  suggested  by  the  Rhode  Island  League  for  the  Sup- 
pression of  Tuberculosis,  which  had  heard  of  the  satisfactory  results 
obtained  by  schools  of  the  kind  in  Europe.  The  pupils  do  not  remove 
their  outer  wraps  unless  the  weather  requires  closing  the  large  windows. 
The  teaching  force  of  the  institution  has  been  selected  largely  from 
experienced  instructors,  and  is  under  the  direction  of  a  corps  of  experts 
who  have  made  a  special  study  of  the  subject. 

The  dispensary  and  the  advice  stations  will  always  have  to  serve  as 
a  clearing  house. 

Day  Camps  (Walderholungsstatten) . — As  an  intermediary  between 
the  dispensary  and  hospital  sanatorium  there  were  established  in  Ger- 
many so-called  day  camps  (Walderholungsstiitten),  situated  in  city  parks 
or  near-by  forests.  There  ambulatory  patients  spend  the  greater  part 
of  the  day,  enjoying  the  open  air,  resting  on  reclining  chairs  or  taking 
walks,  all  under  careful  medical  supervision. 

Many  such  stations  also  provide  good  substantial  lunches.  In  the 
United  States  the  first  day  camp,  or  day  sanatorium,  was  established 


CLASS  METHOD   AT   HOME  441 

near  Boston  on  Parker  Hill  under  the  auspices  of  the  Boston  Associa- 
tion for  the  Kelief  and  Control  of  Tuberculosis.  The  camp  furniture 
is  of  the  simplest  sort,  consisting  of  reclining  chairs  and  a  few  cots  for 
such  patients  as  may  be  feverisli.  The  patients  come  regularly,  and 
are  brought  up  the  steep  hill  to  the  camp  each  morning,  between  8  and 
9.30  A.]\[.,  in  a  barge  which  meets  them  at  Koxbury  Crossing.  Between 
5  and  6  p.m.  they  walk  slowly  down  the  hill  to  the  electric  cars  on 
Huntington  Avenue,  and  return  to  their  homes.  A  substantial  hot 
dinner  is  served  in  the  mess  tent  about  noon,  also  a  lunch  on  arrival 
in  camp,  and  again  just  before  leaving. 

New  York's  Ferryboat  Day  Camp. — In  Xew  York  City  the  estab- 
lishment of  near-by  day  camps  on  land  is  practically  out  of  the  question, 
owing  to  the  distance  the  patients  would  have  to  go.  The  only  availal^le 
site  for  such  an  undertaking  would  be  far  up  in  the  Bronx,  and  the  tire- 
some journey  by  the  sul)way  or  elevated  railroad  would  offset  any 
benefit  that  would  be  derived  during  the  period  spent  at  the  camp. 
The  Committee  on  Tuberculosis  of  the  Charity  Organization  Society 
therefore  gladly  accepted  the  offer  to  utilize  for  that  purpose  one  of 
the  city  ferryljoats  out  of  commission.  Moored  out  at  the  end  of  the 
pier  at  West  Sixteenth  Street  is  the  old  Staten  Island  ferryboat  South- 
field,  New  York's  newest  day  camp  for  consumptives.  Pronounced 
unseaworthy,  the  old  boat  is  still  doing  its  part  in  the  service  of  the 
city,  and  its  decks,  once  thronged  with  an  impatient  crowd  going  to 
and  from  their  work,  now  afford  rest,  fresh  air,  and  sunshine  for  those 
who  are  battling  with  disease.  The  patients  sent  there  from  the  dis- 
pensaries by  private  physicians  (usually  from  fifty  to  one  hundred  in 
number)  pass  their  days  there,  reclining  in  the  sunshine  and  being 
benefited  by  the  fresh  river  breezes. 

The  camp  is  under  the  supervision  of  a  trained  nurse  with  a  suf- 
ficient number  of  assistants.  The  patients  have  the  use  of  steamer 
chairs  and  present  quite  a  cheerful  gathering.  There  has  been  a  gain 
in  weight  of  nearly  all  the  patients  sent  to  this  unique  day  camp.  The 
routine  day  begins  with  the  taking  of  temperatures  and  weighings. 
Ail  the  nourishing  food  that  can  be  given  is  eaten.  There  is  an  abun- 
dance of  fresh  eggs  and  milk.  Each  patient  eats  from  three  to  eight 
eggs  a  day  and  drinks  from  three  to  eight  glasses  of  milk.  Some  of  the 
patients  bring  light  luncheons  themselves,  although  bread,  butter,  and 
coffee  are  served  on  the  boat  at  the  expense  of  the  society.  Regular 
visits  are  paid  by  physicians  who  are  medical  members  of  the  tubercu- 
losis committee. 

Class  Method  at  Home. — Another  way  of  taking  care  of  the  con- 
sumptive poor  who  must  be  treated  at  their  homes  is  the  so-called  class 
method,  which  owes  its  origin  to  the  zeal  and  devotion  of  Dr.  Joseph 


442     PUBLIC   MEASURES   IN   THE   PROPHYLAXIS   OF   TUBERCULOSIS 

A.  Pratt,  of  Boston.  To  define  tlie  class  methods  with  treatment  of 
tuberculous  patients,  one  might  say  a  number  of  patients,  who  for  one 
reason  or  another  cannot  be  under  institutional  treatment,  are  placed 
under  the  care  of  a  physician  or  nurse  or  a  friendly  visitor,  and  the 
sanatorium  treatment  at  home  is  applied  throughout  the  year  in  order 
to  obtain  improvement  or  cure. 

The  patients  may  sleep  outdoors  in  tents  on  roofs  or  extensions,  and 
when  this  is  not  feasible  a  window  tent,  an  aerarium,  a  sleeping  canopy, 
or  some  similar  device  can  be  installed.  If  these  are  not  available  the 
windows  of  bedrooms  are  left  wide  open.  Patients  spend  the  greater  part 
of  the  day  outdoors,  at  rest,  or  taking  careful  walking  or  respiratory 
exercises.  Patients  keep  a  record  of  their  daily  doings,  including  tem- 
perature, cough,  etc.  They  meet  weekly  to  report  to  their  physician  and 
for  the  purpose  of  social  intercourse.  They  are  visited  daily  by  the 
nurse  or  friendly  visitor  who  devotes  all  her  time  to  that  piirpose. 

Before  anyone  is  admitted  to  such  a  class,  a  promise  of  cessation  of 
work  and  implicit  obedience  to  the  rules  of  the  class  is  exacted.  Such 
classes  should  never  be  larger  than  from  10  to  25,  for  more  are  hard 
to  supervise  by  one  nurse.  To  relieve  the  feature  of  possible  pauper- 
ization, a  small  fee  or  membership  due  should  be  charged  to  all  patients 
able  to  pay.  The  Emanuel  Church  Tuberculosis  Class  of  Boston  charges 
for  this  $2  per  month.  Since  Dr.  Pratt's  successful  venture  with  this 
method  a  number  of  cities  have  installed  the  class  system,  all  with  grati- 
fying results. 

Special  Relief  Work  of  Tuberculosis  Committee  of  the  C.  0.  S.,  New 
York. — Another  matter  of  great  importance  which  will  help  in  taking 
care  of  the  consumptive  poor  has  been  taken  up  by  the  Charity  Organi- 
zation Society's  Tuberculosis  Committee,  which  under  the  supervision 
of  a  subcommittee  on  relief  work  helps  patients  to  come  under  the 
observation  of  the  society's  agents.  The  following  is  taken  from  the 
society's  report  of  1906,  referring  to  the  work  done  by  the  committee 
for  the  year  1905-1906: 

That  suitable  cases  might  leave  their  families  to  enter  hospitals 
and  sanatoriums,  there  has  been  given  to  15  persons  relief  in  the  form 
of  "  wage  loss,''  the  term  used  to  denote  the  amount  paid  in  to  con- 
sumptive families  to  make  up  the  wages  lost  by  the  consumptive  through 
ceasing  work  in  pursuance  of  advice  given. 

Twenty-two  other  families  have  been  moved  into  better  rooms,  the 
committee  paying  moving  expenses  and  excess  of  the  new  rent,  as  the 
case  might  be. 

Rent  has  been  paid  for  36  others  in  their  former  apartments,  where 
these  rooms  were  suitable  and  where  also  there  was  a  separate  room  for 
the  consumptive. 


RELIEF  WORK  OF  Tl^BERCULOSIS  COMMITTEE  OF  THE  C.  O.  S.     443 

For  18  others  beds  have  been  supplied,  so  that  the  patient  might 
have  a  separate  bed  in  a  separate  room. 

Special  diet,  usually  in  the  form  of  milk  and  eggs,  has  been  pro- 
vided in  139  cases,  where  the  residence  of  the  patient  was  so  far  re- 
moved from  a  dispensary  or  diet-kitchen  station  that  he  was  practically 
cut  off  from  this  needed  form  of  treatment. 

Clothing  has  been  supplied  to  55  patients  and  sometimes  to  their 
families,  and  is  a  regular  method  of  relief  by  the  committee  in  cases 
going  to  hospitals.  This  form  of  relief  will,  of  course,  become  more 
frequently  necessary  to  patients  exposed  to  the  cold  weather  of  the 
winter  months  while  taking  the  "  fresh-air  cure." 

Through  the  aid  of  the  Committee  on  Employment  for  the  Handi- 
capped, 4  consumptives  have  been  provided  with  employment  of  a  char- 
acter suitable  to  their  physical  condition,  such  as  doorkeepers,  etc. 

Ten  young  girls  and  children  were  maintained  in  whole  or  in  part 
at  pay  sanatoria  for  periods  averaging  one  and  a  half  to  nine  months. 
This  was  done  because  such  treatment,  though  expensive,  seemed  the 
only  method  available  of  effectually  returning  these  patients  to  wage- 
earning  power,  and  the  refusal  to  give  such  treatment  seemed  likely  to 
lead  to  unavoidable  physical  decline  along  with  the  possibility  of  infec- 
tion to  others  of  the  patient's  family.  Seven  patients  through  the  instru- 
mentality of  the  committee  were  sent  to  the  Xew  York  State  Sana- 
torium for  Incipient  Tuberculosis  at  Ray  Brook,  and  provided  with 
clothing  or  such  other  assistance  as  was  necessary.  In  one  of  these 
cases,  of  a  young  girl  of  seventeen  years,  whose  parents  were  continually 
insisting  on  her  working  to  add  to  the  small  family  income,  the  family 
was  prevailed  upon  to  let  her  stay  at  the  sanatorium  for  six  months 
by  the  payment  to  them  each  week  of  $5,  the  amount  the  girl  was 
earning  before  being  taken  out  of  work  by  friends  who  brought  the 
case  to  the  committee's  attention.  In  another  case  the  mother  of  five 
children  was  enabled  to  go  to  this  same  institution  in  the  x\dirondacks 
after  her  children  had  been  sent  to  a  reliable  home  in  the  country, 
where  their  board  was  paid  by  the  committee  for  five  months. 

Seventy  })atients  were  sent  to  the  country  for  stays  varying  from  one 
week  to  five  months,  and  lasting  in  33  cases  for  three  months  or  more,  in 
25  cases  for  two  months  and  a  fraction,  in  9  cases  for  one  month  and  a 
fraction,  in  2  cases  for  half  a  month,  and  in  1  case  for  one  week. 

Tuberculous  patients  in  the  first  stage  of  the  disease,  able  and 
obliged  to  work,  but  who,  by  reason  of  their  poverty,  are  forced  to  sleep 
in  unsanitary  and  overcrowded  homes,  may  be  helped  toward  the  cure 
of  their  disease  by  providing  for  them  what  might  justly  be  called 
Night  Camps.  Here  they  could  receive  at  least  a  good  supper  and  a 
good  breakfast,  could  be  instructed  in  the  hygiene  and  prevention  of 


444    PUBIJC  MEASURES  IN  THE   PROPHYLAXIS  OF   TI'BERCULOSIS 

tuberciilosis,  and  be  assured  of  a  good  night's  rest  in  a  well-ventilated 
room,  tent,  or  shack.  Any  city  could  arrange  for  such  a  night  camp 
on  empty  lots  within  or  in  the  suburbs  of  the  town,  and  a  great  deal 
of  good  would  be  accomplished  thereby. 

The  special  hospital  should  be  located  at  not  too  great  a  distance 
from  the  city,  and  should  receive  the  seemingly  hopeless  or  more  ad- 
vanced eases.  If  any  of  the  latter  should  improve  they  can  easily  be 
sent  to  a  sanatorium.  The  sanatorium  stands,  of  course,  for  what  its 
name  implies — a  healing  institution.^ 

Maternity  Sanatoria. — Besides  the  sanatorium  for  consumptive 
adults  and  tuberculous  children,  there  should  be  in  every  large  com- 
munity either  a  special  maternity  sanatorium  or  a  special  ward  in  an 
existing  maternity  hospital  where  tuberculous  mothers  could  be  received 
a  few  months  previous  to  their  confinement,  and  surrounded  by  the  best 
hygienic  and  dietetic  care.  They  should  remain  in  the  sanatorium  for 
some  time  after  childbirth.  It  is  only  by  taking  away  these  mothers 
from  their  unsanitary  tenement  homes,  and  placing  them  under  con- 
stant medical  supervision  in  such  an  institution,  some  time  before  and 
after  their  confinement,  that  the  fearful  mortality  among  tuberculous 
mothers  after  childbirth  can  be  reduced. 

The  beneficial  effect  on  the  woman's  and  child's  constitutions  that 
might  thus  be  accomplished  can  hardly  be  overestimated.  Leaving  aside 
the  physical  well-being  thus  largely  assured  to  mother  and  child  at  a 
period  when  their  organisms  need  the  most  tender  care,  the  hygienic 
training  which  the  mother  will  have  received  in  such  an  institution 
will  be  of  lasting  utility  to  herself,  to  the  family,  and  to  the  community. 

These  maternity  sanatoria  need  not  be  situated  at  a  great  distance 
from  the  city.  All  that  would  be  essential  is  that  they  should  be  erected 
on  good,  porous  ground,  preferably  somewhat  elevated,  and  in  a  locality 
where  the  atmosphere  is  as  pure  as  possible.  The  buildings  should  be 
constructed  in  accordance  with  the  principles  of  modern  obstetric  sci- 
ence and  modern  phthisiotherapy.  The  physician  in  charge  should  be 
experienced  in  both  these  branches  of  medicine. 

'The  vvord  sanatorium  is  used  in  preference  to  the  word  "sanitarium"  for  the 
following  reasons:  Brehmer,  the  founder  of  the  first  institution  of  that  kind,  called  it 
"Heilanstalt, "  which  means  a  healing  institution;  and  the  word  "sanatorium," 
from  the  Latin  sanare,  to  heal,  gives  certainly  a  better  equivalent  to  the  German 
word  than  the  word  "sanitarium."  This  latter  word  is  derived  from  the  Latin 
sanitas,  health,  and  is  usually  employed  in  this  country  to  designate  a  place  con- 
sidered as  especially  healthy,  a  favorite  resort  for  convalescent  patients,  or  an 
institution  for  the  treatment  of  mental  or  nervous  diseases.  The  word  sanatorium 
for  institutions  for  the  tuberculous  is  now  almost  imiversally  accepted,  and  the 
United  States  Government  has  officially  accepted  it  by  calling  the  government 
institutions  by  that  name. 


SOCIAL   MISSION   OF   THE  TFBERCrLOSIS   SANATORIUM       445 

Medical  Mission  of  the  Tuberculosis  Sanatorium. — The  modern  and 
ideal  sanatorium  for  the  treatment  of  consumptives  has  a  medical  and 
a  social  mission.  The  medical  mission  is  manifold.  By  the  admission 
of  a  patient  to  an  institution,  a  dangerous  center  of  infection  is  sup- 
pressed and  the  patient  is  given  the  greatest  possible  chance  of  cure. 
If  in  the  advanced  stage,  he  is  made  as  comfortable  as  lies  in  the  power 
of  human  skill  with  all  the  modern  therapeutics  at  command.  The 
sanatorium  teaches  that  phthisiophobia  is  as  unjust  as  it  is  cruel.  It 
shows  that  the  careful  and  conscientious  consumptive  is  as  safe  an  indi- 
vidual to  associate  with  as  anybody  else,  and  that  sanatoria  for  con- 
sumptives are  not  a  danger  to  the  neighborhood.  It  cures  the  consump- 
tive whenever  his  case  is  curable,  and  demonstrates  the  curability  of  the 
disease  independently  of  climate.  It  makes  the  patient  a  hygienic  fac- 
tor when  he  returns  to  his  former  environments  and  demonstrates  the 
preventability  of  tuberculous  diseases.  The  patient  will  have  been 
taught  the  love  of  fresh,  pure  air  by  day  and  by  night,  to  shun  a  vitiated 
atmosphere  and  the  air  of  the  saloon  and  the  crowded  meeting  place. 
He  will  have  learned  the  value  of  simple,  pure,  and  good  food,  and  how 
much  more  advantageous  it  is  for  him  and  his  children  to  spend  his 
money  for  food  than  for  intoxicating  liquors. 

The  sanatoria  for  children,  some  of  which  report  as  many  as  seventy- 
five  per  cent  of  cures,  prevent  many  a  strongly  predisposed  child  from 
ever  becoming  a  consumptive  in  later  years  or  going  through  life  crip- 
pled or  deformed. 

Social  Mission  of  the  Tuberculosis  Sanatorium. — In  summarizing  the 
social  mission  of  the  sanatorium  for  tuberculous  patients,  we  behold  an 
even  greater  destiny.  The  sanatorium  teaches  true  democracy,  compas- 
sion and  benevolence  to  the  aristocratic,  the  rich,  and  the  indifferent. 
It  teaches  the  fallacy  of  a  belief  in  alcohol  as  a  food  or  specific  for 
tuberculosis,  and  thus  combats  alcoholism.  It  teaches  the  disorderly 
to  become  orderly  and  offers  to  the  uneducated  an  opportunity  for  edu- 
cation. It  teaches  love  for  fresh  air,  personal  and  general  cleanliness, 
and  thus  indirectly  prevents  not  only  tuberculosis,  but  many  other  dis- 
eases whose  origin  must  be  traced  to  lack  of  fresh  air,  to  filth,  and  to 
unsanitary  habitation  and  habits. 

The  young  medical  man,  entering  the  sanatorium  as  assistant,  is 
given  an  opportunity  to  become  a  trained  diagnostician  of  incipient 
tuberculosis,  and  thus  he  will  be  most  helpful  in  the  solution  of  the 
tuberculosis  problem. 

It  has  been  asked  what  shall  become  of  the  numl)er  of  sanatorium 
buildings  when  tul)erculosis  will  have  so  decreased  as  no  longer  to  till 
them?  This  is  a  question  tliat  probal>ly  will  not  have  to  be  answered 
for  some  time;  nevertheless,  by  reason  of  their  location  and  construe- 


446    PUBLIC  MEASURES  IN  THE   PROPHYLAXIS  OF  TUBERCULOSIS 

tion,  the  sanatoria  for  adults  will  make  admirable  homes  for  the  aged 
and  infirm  who  now  crowd  the  almshouses  and  poorhouses,  and  the 
seaside  sanatoria  will  give  to  the  children  and  overworked  mothers  of 
our  crowded  cities  much-needed  vacation  homes. 

Duty  of  the  Municipality  toward  the  Family  of  the  Consumptive. — 
While  it  is  the  duty  of  all  municipalities  and  philanthropic  institutions 
taking  care  of  the  consumptive  poor  and  those  of  moderate  means  to  be 
assured  that  the  rest  of  the  family  do  not  suffer,  and  by  privation  also 
become  victims  of  the  disease  while  the  breadwinner  is  in  the  sana- 
torium, it  is  of  equal  importance  to  use  all  possible  means  to  prevent 
pauperization.  A  careful  inquiry  into  the  financial  condition  of  every 
patient  entering  a  people's  sanatorium  is  as  important  as  taking  down 
the  medical  history  and  making  the  ph3^sical  examination.  By  a  visit 
to  the  home  of  a  poor  consumptive,  after  he  has  left  for  the  sanatorium, 
much  may  he  learned  in  the  interest  of  all  concerned.  If  the  home  is 
unsanitary,  it  should  be  brought  to  the  attention  of  the  respective 
authorities;  if,  for  no  fault  of  the  family,  there  is  want  of  food,  fuel, 
or  garments,  they  should  be  provided  with  these,  and  everyone  who  has 
lived  with  the  patient  now  in  the  sanatorium  should  be  examined  to 
discover  if  there  exists  tuberculosis,  some  other  disease,  or  a  predisposi- 
tion to  any.  By  attending  to  these  matters  in  time  the  municipality 
will  again  save  money  and  lives.  All  this  will  be  owing  to  the  direct 
and  indirect  influence  of  the  sanatorium. 

Preventatorium. — A  rather  unique  type  of  institution  for  the  tu])er- 
culous  owes  its  inception  to  Dr.  Arthur  J.  Richer,  of  Montreal,  Canada. 
Dr.  Richer  conducts,  under  the  name  of  "  Brehmer  Rest,"  at  Ste. 
Agathe  des  Monts,  a  charitable  institution  for  the  sole  purpose  of  sav- 
ing adults  predisposed  to  tuberculosis  from  developing  it.  The  class  of 
patients  received  at  Brehmer  Rest  are  those  convalescent  from  pneu- 
monia, pleurisy,  and  typhoid  fever,  or  such  as  are  affected  with  chronic 
anemia,  chlorosis,  or  who  are  so  generally  debilitated  by  other  causes 
as  to  make  them  fit  soil  for  the  invasion  of  the  tubercle  bacilli.  A 
sojourn  of  two  or  three  months  at  Brehmer  Rest  usually  suffices  to  over- 
come the  tuberculous  predisposition  and  to  train  the  patient  to  be  careful 
so  that  he  may  never  develop  the  disease. 

It  must  be  evident  that  this  is  a  great  preventive  work.  The  writer 
has  visited  Brehmer  Rest  and  convinced  himself  of  the  good  which  may 
be  accomplished  by  this  method  of  treating  a  pretuberculous  state,  if 
it  may  be  so  designated.  He  has  suggested  to  Dr.  Richer  the  name  of 
"  preventatorium,"  or  preventorium,  for  the  institution,  and  Dr.  Richer 
thought  favorably  of  it.  The  name  Brehmer  Rest  hardly  conveys  the 
idea  for  which  the  institution  stands,  while  the  word  preventatorium 
means  an  institution  consecrated  to  the  cause  of  prevention. 


COMPULSORY   NOTIFICATION   OF  TUBERCULOSIS  CASES       447 

It  would  seem  that  the  preventatorium  as  conceived  by  Dr.  Eicher 
is  perhaps  as  essential  a  weapon  to  combat  tuberculosis  in  the  adult, 
or  to  prevent  its  development,  as  "  L'Qiuvre  de  preservation  contre  la 
tuberculose  des  enfants,"  called  into  life  by  the  late  Professor  Grancher 
of  Paris,  is  for  the  child.  One  saves  children,  the  other  adults,  from  con- 
tracting the  disease  by  fortifying  the  system  against  the  probable  inva- 
sion of  the  tul^ercle  bacillus.  Works  like  that  of  Professor  Grancher  and 
that  of  Dr.  Richer  are  striking  at  the  very  root  of  the  evil,  and  the  more 
preventatoriums  for  adults  and  the  more  "  preservatoriums  "  for  children 
we  have,  the  more  readily  shall  we  master  the  tuberculosis  problem. 

Agricultural  and  Horticultural  Colonies. — Lastly,  for  the  cured  and 
arrested  cases  Ave  will  have  to  create  agricultural  and  horticultural  colo- 
nies, or  other  industries  whereby  the  recovered  pulmonary  invalid  may 
have  a  chance  to  make  his  cure  lasting  by  following  a  healthful  out- 
door occupation  for  some  time  before  returning  to  his  old  trade  or 
profession. 

While  much  has  been  done,  there  is  more  to  do,  and  we  in  America 
are  far  removed  from  the  time  when  we  shall  have  too  many  sanatoria 
for  adults  or  children.  The  municipal.  State  and  Federal  governments 
should  combine  with  individual  efforts  more  energetically  than  hereto- 
fore in  the  establishment  of  all  institutions  intended  for  the  preservation 
and  treatment  of  tuberculosis. 

Remuneration  of  Physicians  in  Public  Tuberculosis  Institutions. — 
There  is  one  point,  however,  which  the  municipality  must  bear  in  mind. 
It  has  been  shown,  when  speaking  of  the  economic  value  of  the  cured, 
individual,  that  the  municipality  gains  directly  financially  and  indirectly 
socially.  The  bulk  of  the  work  in  dispensaries  and  advice  stations,  in 
treatment  of  the  poor  at  home,  in  special  hospitals,  and  sanatoria,  must 
be  done  by  the  physician.  The  latter  must  devote  a  great  deal  of  his 
time  to  this  cause.  It  is  but  right,  reasonable,  and  just,  therefore,  that 
a  physician  devoting  a  number  of  hours  daily  to  the  patients  in  the 
dispensaries,  special  hospitals,  and  other  institutions  where  the  poor  are 
received,  should  be  remunerated  properly.  When  the  community  is  the 
financial  gainer  through  the  physician's  work  and  devotion,  the  latter 
must  not  be  the  financial  loser. 

Compulsory  Notification  of  Tuberculosis  Cases  and  the  Work  of  the 
Health  Department  in  Relation  Thereto. — A  municipality  which  makes 
registration  compulsory  accomplishes  but  one  half  of  its  work  when  it 
does  not  at  the  same  time  supply  sanatoria  and  hospitals  for  cases  which 
cannot  be  properly  treated  at  home.  But  where  such  sufficient  provision 
exists,  compulsory  notification  of  tuberculous  cases,  when  tactfully  in- 
augurated and  carried  out,  cannot  but  be  productive  of  good,  and  will 
further  the  interests  of  the  general  practitioner,  the  patient,  and  the 


448    rUBLIC   MEASURES  IN   THE   PROPHYLAXIS  OF   TIBERCULOSIS 

community  as  well.  A  partially  voluntary  and  partially  compulsory 
notification  of  tuberculous  cases  was  first  inaugurated  in  New  York  by 
Dr.  Hermann  M.  Biggs,  of  the  Health  Department,  in  1893.  Public 
institutions  were  required  to  report  cases  coming  under  their  super- 
vision, and  private  physicians  were  requested  to  do  so.  Under  this  pro- 
vision the  Department  of  Health  carried  on  this  work  for  three  and  a 
half  years,  and  then  adopted  in  1897  regulations  requiring  the  notifica- 
tion of  all  cases. 

The  following  is  a  card  which  the  Health  Department  furnishes  to 
the  practitioner  for  him  to  utilize  in  notifying  the  department  of  a  case 
of  tuberculosis.  It  shows  for  itself  that  no  interference  on  the  part 
of  the  department  is  intended. 

REPORT   OF   CASE   OF   TUBERCULOSIS 

New  York, 190 

Name  of  Patient Age 

Sex Occupation Color Nationality 

Residence Care   of 

No.  families  in  house No.  in  family 

Previous  cases  in  family 

Do  you  wish  an  Inspector  to  visit  the  premises  and  instruct  the  family  regarding 

prophylaxis?     Answer  Yes  or  No 

M.D. 

Residence 

Note — Private  cases  of  tuberculosis  where  tliere  is  a  physician  in  attendance  will  NOT  be 
visited  by  the  Department  of  Health  except  upon  request. 

The  same  tact  is  used  in  the  case  of  a  dispensary  patient,  and  the 
dispensary  assures  the  department  that  patients  are  sufficiently  in- 
structed and  supervised.  The  following  is  the  card  nsed  for  that  pur- 
pose. Institutions  which  treat  a  number  of  cases  of  tuberculosis  receive 
special  cards  for  the  purpose  of  reporting. 

DISPENSARY  TUBERCULOSIS  CARD 

REQUEST    NOT   TO   VISIT 

New  York, 190 

Name  of   Patient Age 

Sex Occupation Color Nationality 

Residence Care   of 


This  case  is  under  supervision  at  home  and  the  Department  of  Health  is  there- 
fore requested  NOT  to  send  a  nurse  or  inspector  to  visit  the  patient.  Notice  will 
be  sent  of  any  change  of  address,  or  discontinuance  of  attendance. 


(Name  of  Dispensary  or  Charitable  Organization  reporting  case) 

Note — This  card  is  simply  a  request  not  to  visit,  and  is  not  a  report.  All  cases  must  also  be 
reported  in  tlie  regular  way:  by  special  institution  postal  card  or  by  the  sending  of  a  specimen  of 
sputum.  Private  cases  of  tuberculosis  where  there  is  a  i)hysician  in  attendance  will  not  be  visited 
by  the  Department  of  Health  except  upon  request. 


COMPULSORY   NOTIFICATION   OF   TIBERCULOSIS  CASES       449 

Dr.  H.  M.  Biggs  ("04)  showed  the  value  of  compulsory  notification 
when  combined  with  sanitary  supervision  and  sanatorium  and  hospital 
provisions.     He  says: 

During  the  last  ten  years  there  has  been  a  decrease  of  forty  per  cent 
in  the  death-rate  in  children  under  fifteen  years  in  pulmonary  tuberculosis 
and  tuberculous  meningitis,  these  being  the  two  forms  of  tuberculous  dis- 
ease in  which  an  approximately  accurate  diagnosis  is  likely  to  be  made. 
It  is  precisely  in  this,  the  youngest  element  of  the  population,  that  one 
would  first  look  for  definite  results  from  the  enforcement  of  measures  for 
the  restriction  of  the  disease. 

It  would  seem  that  this  remarkable  result  certainly  justifies  compul- 
sory registration.  The  methods  adopted  by  the  Xew  York  Health  De- 
partment have  been  looked  on  as,  perhaps,  the  best  and  most  efficient, 
and  for  this  reason  a  description  of  the  routine  procedure  adopted  by 
the  Health  Department,  as  it  has  been  tersely  given  by  John  S.  Billings, 
Jr.   ('06),  is  of  interest: 

The  sanitary  supervision  of  pulmonary  tuberculosis  in  the  different 
boroughs  of  the  city  is  carried  on  by  means  of  the  same  staff  of  inspectors 
who  administer  diphtheria  antitoxin.  The  staff  of  nurses  is  apportioned 
as  follows:  Manhattan,  seven;  Brooklyn,  four;  Bronx,  one,  and  Richmond 
and  Queens,  one.  Each  nurse  has  a  certain  section  of  the  city  assigned 
to  her. 

Cases  of  tuberculosis  are  reported  to  the  Department  of  Health  by 
(1)  private  physicians,  (a)  on  the  postal  cards  furnished,  (b)  by  the  for- 
warding of  specimens  of  sputum  for  examination  to  the  Diagnosis  Labora- 
tory; (2)  institutions  (hospitals,  sanatoria,  dispensaries),  on  postal  cards 
furnished;  (3)  death  certificates,  forwarded  to  the  Bureau  of  Records; 
(4)  complaints  from  lay  individuals  or  organizations;  (5)  employees  of 
this  and  other  departments  of  the  city. 

The  various  records,  files,  indices,  etc.,  of  cases  of  pulmonary  tubercu- 
losis center  around  an  alphabetical  "  name "  index,  in  which  the  name, 
age,  address,  date,  case  number,  and  source  of  report  of  every  living  case 
are  entered,  together  with  the  name  of  the  subindex  in  which  the  record 
card  is  filed.  The  actual  record  cards  are  filed  in  different  subindiees 
according  to  circumstances,  as  follows: 

1.  "Private  cases"  (p.  c.  on  name  card),  reported  by  private  physi- 
cians and  not  visited  by  inspectors  or  nurses. 

2.  "  At  home "  (a.  h.  on  name  card) ;  cases  at  their  homes  under 
supervision  by  the  department  (i.  e.,  not  under  the  care  of  the  physician). 

3.  "Hospital"  cases  ("  hosp."  in  the  space  for  name  of  institution), 
reported  as  having  entered  a  hospital. 

4.  "Not  found"  cases  (n.  f.) ;  those  not  found  at  address  under  which 

reported. 

30 


450    PUBLIC  MEASURES  IN  THE   PROPHYLAXIS  OF  TUBERCULOSIS 

5.  "  Dead  "  cases  (name  card  is  destroyed). 

6.  "  Out  of  town  "  cases   (o.  o.  t.)  ;  reported  as  having  left  the  city. 

7.  "  No  case  "  and  "  Recovered  "  (n.  c.)  ;  found  on  investigation  not 
to  be  cases  of  tuberculosis,  or  reported  as  recovered. 

On  the  receipt  of  report  of  a  case,  from  whatever  source,  it  is  first 
searched  for  in  name  index.  If  it  is  a  (previously  unreported)  case,  a 
record  case  number  is  assigned  (beginning  each  January  1),  which  is 
written  on  the  original  postal  card  or  report  card  from  Diagnosis  Laboi'a- 
tory  in  red  ink.  If  an  old  case  (a  duplicate),  the  old  number  is  written 
in  black  ink.  A  blue  "  record "  card  is  then  made  out,  on  which  all 
essential  facts  are  entered,  and  (later)  every  official  action  and  recom- 
mendation of  the  department,  dates  of  inspection  and  by  whom,  records 
of  fumigation  and  renovation,  forcible  removal,  etc.,  changes  of  address, 
entrance  into  hospital,  duplicate  reports,  etc.,  are  also  noted  on  this  card. 
The  original  report  is  then  filed  in  "  report  card  "  index,  according  to  date 
of  receipt.  Only  postal  cards  and  sputum  report  cards  are  so  filed;  all 
other  forms  of  reports  are  transferred  to  a  postal  card  before  filing.  This 
index  is  kept  for  five  years. 

A  record  is  kept  of  every  case  assigned  to  an  inspector  or  nurse  by 
means  of  a  "  tally  "  index  showing  exactly  what  cases  are  being  investi- 
gated by  each  inspector  and  nurse.  A  small  "  tally  "  card  for  each  case 
is  filed  under  the  employee's  name,  and  is  only  removed  on  receipt  from 
him  or  her  of  all  cards,  etc.,  relating  to  the  case.  This  index  is  gone  over 
once  a  week  and  any  delays  inquired  into. 

Private  cases  are  not  visited  except  at  the  request  of  the  attending 
physician.  A  letter  is  sent  to  the  physician  acknowledging  receipt  of 
report,  calling  his  attention  to  the  necessity  for  reporting  any  change  of 
address  or  discontinuance  of  treatment  on  the  part  of  the  patient,  and 
inclosing  a  circular  of  instruction,  which  (or  its  equivalent)  the  physi- 
cian is  requested  to  give  to  the  family  of  the  patient  or  to  the  patient 
himself.  A  card  index  is  kept  of  the  names  of  all  physicians  reporting 
"  private  "  cases,  together  with  the  names  of  cases.  The  large  record  card 
is  then  filed  in  the  "  private "  case  index  according  to  patient's  address. 
Once  a  year  a  letter  is  sent  to  the  attending  physician  of  every  "  private  " 
case,  asking  for  information  as  to  outcome  of  case.  If  no  answer  is 
received,  the  case  is  followed  up  by  the  department.  Such  eases,  if 
found  (also  all  "private"  cases  reported  later  by  institutions),  come 
under  the  supervision  of  the  department,  the  "  p.  c."  on  name  card  being 
stricken  out. 

At  home  cases  are  reported  by  (a)  dispensaries  and  charitable  organ- 
izations, (h)  laymen,  (c)  physicians,  with  request  that  they  be  visited, 
and  (d)  hospitals,  as  having  been  discharged.  Such  cases  are  at  once 
assigned  for  investigation  and  report  to  the  nurse  in  whose  district  the 
patient  lives.  The  date  of  assignment  and  name  of  nurse  are  entered  on 
blue  record  card,  which  is  mailed  to  the  nurse.  If  the  patient  is  found, 
a  pink  "  observation  "  card  is  filled  out,  giving  all  essential  data  (if  not 
foimd,  that  fact  is  noted  on  record  card,  which  is  returned).     Record  and 


COMPULSORY   NOTIFICATION   OF  TUBERCULOSIS  CASES       451 

observation  cards  are  returned  by  mail  on  the  day  of  inspection.  Any 
recommendations  (hospital,  charitable  aid,  etc.)  are  indicated  by  writing 
date  in  proper  space  on  record  card.  If  case  is  kept  under  observation,  a 
white  "  nurse's "  card  is  tilled  out  and  returned,  on  same  being  entered 
all  records  of  w-eekly  visits.  On  termination  of  supervision  (by  death, 
improvement,  removal  to  hospital,  removal  outside  nurse's  district,  etc.) 
the  nurse's  card  is  returned.  Recommendations  by  nurse  during  observa- 
tion or  on  termination  of  case  (for  disinfection,  forcible  removal,  etc.) 
are  made  on  a  special  postal  card.  On  receipt  of  record  at  borough  office, 
(1)  if  tuberculosis  case  was  "not  found,"  that  fact  is  indicated  on  name 
card  and  in  book  for  recording  number  of  "  not  found "  cases,  and  card 
is  filed  in  "  not  found  "  index.  A  letter  is  sent  to  individual  who  reported 
the  case,  requesting  correct  address.  (2)  If  found,  the  record  card  is 
stamped  "  observation  card  "  on  left-hand  margin,  and  filed  in  "  at  home  " 
index.  If  not  to  be  kept  under  observation  by  the  nurse,  the  pink  "  ob- 
servation "  card  is  filed  with  it ;  if  kept  under  observation,  the  pink  card 
is  filed  in  the  "  tally  "  index  under  nurse's  name,  forming  record  of  cases 
under  her  observation.  Each  week  a  record  is  kept  of  number  of  cases 
under  observation  in  each  district.  On  return  of  white  "  nurse's  "  card, 
it  is  attached  to  observation  card  and  record  card,  and  appropriately 
filed. 

Cases  needing  charitable  assistance  are  referred  to  the  Charity  Or- 
ganization Society,  Association  for  Improving  the  Condition  of  the 
Poor,  United  Hebrew  Charities,  Brooklyn  Bureau  of  Charities,  etc.,  by 
telephone  and  postal  card,  a  card  index  being  kept  of  all  such  recom- 
mendations. 

Milk,  two  quarts  daily  for  one  month;  eggs,  three  daily  for  two  weeks, 
are  issued  in  cases  where  such  extra  diet  is  called  for  as  a  part  of  treat- 
ment. On  recommendation  of  the  nurse  an  order  on  the  nearest  depot  is 
issued,  a  record  being  kept  of  all  recommendations.  The  following  are 
the  depots: 

Manhattan  Diet  Kitchen  Association:  Raj'mond  Kitchen,  423  West 
Forty-first  Street;  Rusch  Kitchen,  146  East  Seventh  Street;  Freeman 
Kitchen,  335  East  Twenty-first  Street;  Wickham  Kitchen,  137  Centre 
Street;  Gibbons  Kitchen,  140  East  Ninety-seventh  Street;  Hackley 
Kitchen,  26  Barrow  Street;  Anne  Barbara  Kitchen,  205  West  Sixty-second 
Street.  Brooklyn:  Brooklyn  Bureau  of  Charities.  1600  Fulton  Street,  191 
Marcy  Aveime,  69  Sehermerhorn  Street,  174  Johnson  Street,  98  Sackett 
Street,  255  Division  Avenue. 

Sputum  cups,  both  pocket  and  home  (metal  framed  with  removal  fill- 
ing), are   issued  by  the  nurses. 

Instructions  are  given  to  the  patient  and  his  family,  both  verbally  and 
by  means  of  the  "  Circular  of  Instruction  to  Consumptives  and  those  Liv- 
ing with  Them"  (see  Appendix),  each  circular  being  printed  in  English 
and  one  other  language — German,  Italian,  Yiddish,  Ruthenian,  Slovak, 
Polish,  Bohemian,  and  Chinese. 

Cases  of  tuberculosis  attending  the  dispensaries  of  Gouverneur,  Belle- 


452    PUBLIC   MEASURES  IN   THE   PROPHYLAXIS  OF   TUBERCTTLOSIS 

vue,  Presbyterian,  and  Harlem  hospitals,  and  the  Vanderbilt  Clinic,  and 
kept  under  observation  by  the  nurses  of  these  dispensaries,  are  not  visited. 
In  order  to  avoid  duplication  of  visits,  these  dispensaries  are  furnished 
with  postals  to  notify  the  department  that  the  case  is  being  kept  under 
observation.  These  postals  are  filed  under  the  name  of  the  dispensary, 
forming  a  record.  Twice  a  year  this  is  compared  with  the  records  at  the 
dispensary.  All  cases  must  also  be  reported  in  usual  way,  but  are  held 
two  weeks  awaiting  receipt  of  special  dispensary  postal.  If  not  received, 
patients  are  visited. 

All  suitable  cases  are  urged  to  enter  a  hospital;  if  consent  is  obtained, 
the  recommendation  is  made  on  proper  space  on  record  card,  date  and 
name  of  institution  preferred  being  given.  If  recommended  to  Riverside 
Hospital,  the  patient's  name  is  placed  on  waiting  list;  when  vacancy 
occurs,  an  admission  card  is  made  out  and  delivered  by  the  district  nurse, 
who  obtains  information  called  for  on  card  and  reports  as  to  necessity  for 
ambulance,  coupe,  etc.  In  emergency  cases,  when  an  ambulance  is  required, 
the  hospital  in  whose  ambulance  district  the  patient  lives  is  requested  to 
remove  the  patient  to  Bellevue,  whence  he  is  transferred  to  the  Metro- 
politan Hospital  or  to  St.  Vincent's  Sanatorium. 

Ambulance  districts  in  the  Borough  of  Manhattan : 

Gouverneur  Hospital^Houston  to  Front  streets.  Bowery  to  East  River. 

Bellevue  Hospital — Houston  to  Forty-second  streets.  Fourth  Avenue  to 
East  River. 

Flower  Hospital — Forty-second  to  Fifty-ninth  streets.  Sixth  Avenue  to 
East  River. 

Presbyterian  Hospital — Fifty-ninth  to  Xinety-sixth  streets,  Fifth  Avenue 
to  East  River. 

Harlem  Hospital — Xinety-sixth  Street  to  Harlem  River,  Lenox  Avenue  to 
East  River. 

J.  Hood  Wright  Hospital — Eighty-sixth  Street  to  Kingsbridge,  Lenox 
Avenue  to.  Xorth  River. 

Roosevelt  Hospital — Twenty-seventh  to  Eightj-sixth  streets.  Eighth  Ave- 
nue to  North  River;  Forty-second  Street  to  Sixth  Avenue  to  Fifty- 
ninth  Street. 

Xew  York  Hospital- — Fourteenth  to  Twenty-seventh  streets,  Fourth  Ave- 
nue to  North  River;  Twenty-seventh  to  Forty-second  streets.  Seventh 
Avenue  to  Park  Avenue. 

St.  Vincent's  Hospital — Fourteenth  Street  to  Canal  Street,  Fourth  Avenue 
to  North  River. 

House  of  Relief — Catherine  Street  to  North  River,  Canal  Street  to  Battery. 

All  requests  for  admission  to  the  hospitals  of  the  Department  of  Chari- 
ties, and  also  to  St.  Joseph's,  Seton,  and  Lincoln  hospitals,  are  referred 
to  the  Department  of  Charities  by  telephone,  by  a  double  card  (one  half 
being  given  to  patient  and  the  other  being  filed  in  borough  office),  and 
by  postal  card. 


COMPULSORY   NOTIFICATION   OF   TUBERCULOSIS  CASES       453 

When  the  necessary  precautions  cannot  or  will  not  be  observed,  and 
when  others  (especially  children)  are  exposed  to  infection,  a  patient  may 
be  removed  to  Kiverside  Sanatorium  by  force,  if  necessary,  even  if  con- 
sent of  patient  or  family  is  not  obtained. 

When  patients  continue  at  work  and  may  be  sources  of  danger  to  their 
fellow  workmen,  the  employer  is  visited  and  notified  as  to  the  danger  of 
infection  and  precautions  to  be  taken.  Placards  forbidding  promiscuous 
spitting  are  furnished  free,  to  be  put  up  in  the  workplace. 

When  it  is  evident  that  premises  will  need  renovation  after  removal 
of  patient,  the  owner  or  agent  is  required  to  promptly  notify  the  depart- 
ment when  such  removal  takes  place,  and  also  as  to  new  address.  A  postal 
card  is  also  left  by  the  nurse  with  such  patients,  on  which  any  change  of 
address  is  reported. 

All  unsanitary  conditions  (bad  drainage,  leaky  plumbing,  etc.)  are 
reported.  If  occurring  in  a  tenement  house,  the  complaint  is  referred  to 
the  Tenement  House  Department ;  if  not,  to  the  Division  of  Inspectors 
of  the  Department  of  Health.  (A  tenement  is  any  house  containing  three 
or  more  families.) 

On  death,  removal  to  a  hospital,  or  change  of  address  of  a  case  "  under 
observation,"  the  district  nurse  is  notified  by  postal  to  return  all  cards,  etc. 

When  patients  are  not  receiving  medical  care  they  are  referred  to  one 
of  the  tuberculosis  clinics  of  the  Department  of  Health,  a  double  refer- 
ence card  being  used,  one  half  being  given  to  the  patient,  and  one  mailed 
to  clinic. 

Every  hospital  must  report  all  discharges  and  transfers  of  cases  of 
tuberculosis.  Every  case  returning  home  is  at  once  visited  to  see  if  treat- 
ment is  being  continued,  instructions  observed,  etc.  Each  morning  a 
report  is  obtained  by  telephone  from  Seton,  Lincoln,  St.  Vincent's,  Metro- 
politan, St.  Joseph's,  and  Riverside  hospitals  of  (a)  all  patients  discharged 
the  day  before  and  (h)  of  all  cases  to  be  discharged  three  days  later.  The 
former  (a)  are  noted  on  a  "discharge  card"  and  visited  at  once,  as  many 
of  these  patients  remain  at  home  onh-  a  day  or  two.  The  latter  (&)  are 
noted  on  a  "  nurse's  discharge  "  card,  and  each  case  assigned  at  once  by 
telephone  to  the  district  nurse  for  investigation  as  to  whether  patient 
should  be  allowed  to  return  home.  She  reports  by  telephone  within  twenty- 
four  hours,  her  report  being  entered  on  card,  which  is  filed,  and  hospital 
notified.  Should  a  patient  returning  to  unfavorable  home  surroundings, 
or  giving  wrong  address,  insist  on  being  discharged,  the  patient  can  be 
transferred  to  Riverside  Hospital. 

All  cases  reported  by  lay  individuals  and  organizations  and  nurses  are 
classed  as  "suspected"  cases  and  are  visited  by  the  district  medical  in- 
spector, who  reports  results  of  physical  examination  and  nature  of  ail- 
ment on  observation  card.  The  original  report  cards  are  filed  separately 
until  the  case  has  been  reported  on,  when  person  reporting  ease  is  notified 
of  result.  If  case  proves  to  be  one  of  tuberculosis  the  usual  routine  is 
followed,  except  that  when  inspector  recommends  that  case  be  kept  under 
observation,  the  record  and  observation  cards  are  filed,  and  a  white  nurse's 


454    PLBLIC   MEASURES  IN  THE   PRorilYLAXIS   OF   TIBERCILUSIS 

card  tilled  out  and  sent  to  district  nurse.  If  not  tuberculosis,  it  is  classed 
as  "  no  case,"  so  recorded  in  name  index,  and  filed.  All  complaints  by 
citizens  (as  to  spitting,  necessity  for  hospital  treatment,  etc.)  are  investi- 
gated by  a  district  inspector,  who  submits  a  formal  report.  If  there  is 
a  physician  in  attendance,  he  is  visited  and  requested  to  see  that  nuisance 
is  abated,  if  one  exists. 

All  apparently  incipient  cases  seen  by  nurses  and  inspectors,  or  calling 
at  borough  offices,  are  referred  by  card  to  a  tuberculosis  clinic  of  the 
department  for  examination  as  to  their  eligibility  for  sanatorium  treat- 
ment. Very  incipient  eases  are  referred  to  the  New  York  State  Hospital 
for  Incipient  Tuberculosis.  Suitable  cases  are  also  referred  to  the  Stony- 
wold,  the  Loomis,  and  the  Adirondack  Sanatoria. 

Only  in  the  most  exceptional  cases  are  children  with  tuberculosis 
allowed  to  attend  school.  Such  cases  are  excluded  from  school  by  medical 
school  inspectors,  pending  their  examination  at  one  of  the  tuberculosis 
clinics  of  the  department,  whence  a  report  is  sent  to  the  Division  of  Con- 
tagious Diseases.  Every  effort  is  made  to  have  such  children  enter  a 
sanatorium  or  hospital. 

Every  hospital  in  New  York  City  is  required  to  report  all  cases  of 
tuberculosis  within  one  week  of  their  admission,  using  a  postal  card  fur- 
nished. Each  hospital  and  dispensary  is  visited  once  a  month  and  their 
supply  of  the  various  rej^orting  cards  replenished.  The  larger  hospitals 
(Bellevue,  Metropolitan,  etc.)  report  daily.  A  weekly  record  book  is  kept 
of  the  number  of  cases  (new  and  duplicate)  reported  by  each  institution 
throughout  the  year.  When  no  report  is  received  within  two  weeks,  in- 
quiry is  made  by  telephone.  The  yearly  totals  are  compared  with  the 
number  of  cases  given  in  the  annual  report  of  each  institution. 

Twice  a  year  (March  1  and  August  1)  a  census  is  taken  of  all  cases 
of  tuberculosis  in  institutions  in  New  York  City,  a  special  blank  being 
supplied  to  each  institution.  These  censuses  are  compared  with  the  "  hos- 
pital index " — i.  e.,  the  cases  supposed  to  be  in  each  hospital — and  all 
discrepancies  investigated,  the  results  for  each  institution  being  recorded. 
Every  case  reported  as  entering  a  hospital  is  assigned  to  a  district  in- 
spector, who  recommends  the  necessary  renovation,  fumigation,  and  dis- 
infection of  bedding,  such  recommendations  being  recorded  in  the  proper 
space  on  the  record  card  by  means  of  the  date.  (It  is  also  stated  if  patient 
will  return  to  premises  or  not.)  According  to  the  condition  of  the  prem- 
ises, the  inspector  may  recommend:  (a)  That  nothing  need  be  done.  This 
is  most  exceptional,  only  obtaining  in  very  clean  apartments  and  those 
where  the  patient  only  spent  one  or  two  nights  on  the  premises,  (h)  That 
the  room  occupied  by  the  patient  be  fumigated  with  formaldehyde,  (r) 
That  the  patient's  room  be  thoroughly  renovated,  the  walls  and  ceilings 
washed  and  recalcimined,  repapered  or  repainted,  and  the  woodwork  and 
floors  be  washed  and  repainted,  the  rest  of  the  apartment  being  fumigated 
with  formaldehyde,  (d)  That  the  whole  apartment  be  renovated.  Reno- 
vation of  the  i^remises  (washing  of  floors  and  woodwork  with  antiseptic 
solution,    repapering,    painting,    and   calcimining)    is    recommended   on    a 


COMPULSORY   NOTIFICATION   OF   TUBERCULOSIS   CASES       455 

complaint  blank,  which,  after  being  approved  and  journalized,  is  for- 
warded to  the  Sanitary  Superintendent  for  enforcement.  When  cancella- 
tion, extension  of  time,  or  modification  of  order  is  asked  for,  the  case  is 
reinspected  by  the  original  inspector.  When  there  is  reason  to  believe 
that  renovation  will  be  evaded,  or  where  the  premises  are  vacated  by  the 
death  or  removal  of  the  patient  and  renovation  has  been  ordered,  the 
inspector  orders  the  premises  placarded.  A  paster  is  then  filled  out  at 
the  borough  office,  journalized,  and  forwarded  to  the  Division  of  Inspec- 
tions to  be  put  up.  When  owner  or  agent  voluntarily  performs  renova- 
tion, that  fact  is  reported,  a  yearly  record  being  kept  of  the  number  of 
such  voluntary  renovations.  Fumigation  with  formaldehyde  and  disin- 
fection of  bedding  is  ordered  on  a  card,  on  which  number  and  size  of 
room,  date  fumigation  is  to  be  performed,  etc.,  are  noted.  All  fumigation 
orders  for  the  day  are  entered  by  inspector  on  a  slip,  which  is  forwarded 
with  the  fumigation  cards  to  the  Division  of  Contagious  Diseases.  In 
an  emergency  the  fumigation  order  can  be  telephoned,  but  the  card  is 
also  submitted.  All  bedding  is  fumigated  before  it  is  removed  for  disin- 
fection, for  the  protection  of  the  department  employees,  and  is  returned 
in  twenty-four  hours.  The  tally  card  of  the  case  is  filed  separately  as  a 
check  on  fumigation.  The  fumigation  card  is  returned  by  Division  of 
Contagious  Diseases  after  its  recommendations  have  been  complied  with, 
and  the  tally  card  is  destroyed  and  fumigation  card  is  filed  according  to 
date,  being  kept  about  four  months. 

On  receipt  of  record  card  from  inspector  it  is  filed  in  "  hospital  index  " 
alphabetically,  according  to  name  of  hospital,  which  is  written  on  a  small 
name  card.  In  cases  reported  as  having  moved  to  a  new  address  or  hav- 
ing left  the  city,  the  same  routine  procedure  is  followed  out.  In  cases  liv- 
ing in  private  houses  disinfection  can  be  done  under  the  supervision  of 
the  attending  physician,  but  he  must  submit  a  certificate.  Lodging 
houses  are  not  disinfected,  that  being  the  duty  of  the  managers  of  such 
houses. 

When  an  inspector  or  nurse  reports  that  no  record  can  be  found  of  a 
case  at  the  address  given,  a  letter  is  written  to  the  person  reporting  the 
case,  requesting  the  correct  address.  If  this  cannot  be  found  the  name 
card  is  marked  "  n.  f."  and  the  record  card  filed  in  the  annual  "  not 
found  "  index.  These  files  are  kept  three  years,  when  the  record  cards  are 
destroyed  and  the  name  cards  removed  from  the  name  index  and  filed  in 
an  "  old  not  found  name  index."  A  daily  record  is  kept  of  the  number 
of  "  not  found  "  cases  reported. 

All  deaths  from  tuberculosis  occurring  during  the  preceding  twenty- 
four  hours  are  reported  daily  by  the  Bureau  of  Records.  The  record  and 
name  cards  are  stamju'd  "  Dc;)d,"  and  the  former  assigned  to  inspectors 
to  order  the  necessary  fumigation,  etc..  the  latter  being  used  as  a  tally 
card,  and  all  cards  of  the  case  filed  in  "dead"  index  for  the  current  year, 
which  is  kept  for  two  years  before  being  destroyed.  Every  previously 
unreported  dead  case  receives  a  special  serial  case  number,  and  a  letter 
is  written  to  the  attending  physician  or  institution  calling  his  attention 


456    PUBLIC   MEASURES   IN   THE   PROPHYLAXIS  OF   TUBERCULOSIS 

to  the  violation  of  the  Sanitary  Code  and  requesting  an  explanation. 
Should  no  answer  be  received,  a  second  letter,  signed  by  the  secretary 
of  the  department,  is  sent,  demanding  an  explanation  on  pain  of  prose- 
cution. A  record  is  kept  under  each  physician's  name  of  all  such  unre- 
ported cases,  nature  of  explanation,  etc.  (unreported  cases  of  typhoid 
fever,  cerebrospinal  meningitis,  etc.,  are  recorded  in  the  same  index). 
All  deaths  from  pneumonia  are  daily  compared  with  tuberculosis  records. 
If  case  had  been  previously  reported  during  life  as  tuberculosis,  an  in- 
spector visits  the  physician  who  signed  the  death  certificate  and  obtains 
an  explanation  of  the  apparent  discrepancy,  submitting  a  report  on  special 
blank.  The  same  is  done  for  all  cases  of  tuberculosis  reported  as  having 
died  from  some  other  cause.  The  Bureau  of  Records  is  also  notified  of 
any  change  of  diagnosis  and  death  certificate  corrected. 

Every  new  case  of  tuberculosis  reported  in  Manhattan  is  plotted  on  a 
large  map  of  the  borough,  which  shows  each  house  ("  not  found  "  cases, 
of  course,  excepted).  The  address  is  written  on  a  small  white  card  (of 
private  cases,  on  receipt  of  postal  or  sputvim  report;  of  all  others,  on 
receipt  of  inspector's  or  nurse's  report  stating  that  patient  did  live  at 
address  given).  In  Richmond  and  Queens  the  cases  are  plotted  on  compo- 
board  map  by  means  of  colored  pins. 

All  cases  are  admitted  here  through  the  Division  of  Communicable 
Diseases,  the  names  and  addresses  of  applicants  being  placed  upon  the  wait- 
ing list.  When  a  vacancy  occurs  an  admission  card  is  filled  out  for  the 
first  eligible  case.  ("  Forcible  removal "  cases  alone  take  precedence.) 
This  is  assigned  to  a  nurse  for  delivery,  who  obtains  data  called  for  on 
card  and  leaves  same  with  patient.  If  coupe  or  ambulance  is  necessary, 
the  borough  hospital  is  requested  to  remove  the  patient.  All  patients 
must  reach  Reception  Hospital,  at  East  Sixteenth  Street,  Manhattan, 
by  1  P.M.,  as  the  boat  leaves  at  that  hour.  Walking  cases  may  cross 
at  East  132d  Street,  whence  a  boat  leaves  every  hour  between  9  a.m. 
and  5  p.m. 

No  patient  is  allowed  out  on  pass  or  is  discharged  until  the  conditions 
at  his  home  have  been  investigated  and  found  satisfactory.  A  daily  report 
of  cases,  deaths,  discharges,  and  admissions  is  received  by  telephone  each 
day  and  added  to  daily  report  to  Sanitary  Superintendent.  Every  case 
admitted,  discharged,  or  dead  is  reported  daily  on  a  special  card,  which  is 
filed  according  to  date. 

All  inspectors  and  nurses  bear  in  mind  that  the  Department  of  Health 
pledges  itself  not  to  interfere  in  any  way  with  cases  of  pulmonary  tuber- 
culosis under  the  care  of  a  private  physician,  except  where  a  complaint 
is  made.  Even  then  the  attending  physician,  if  there  is  one,  is  first  vis- 
ited.    The  source  of  complaint  is  never  divulged. 

The  Inspector-in-Charge  examines  daily  all  cards,  reports,  etc..  for- 
warded by  inspectors  and  nurses,  sees  that  the  various  recommendations 
are  carried  out,  and  various  records,  map  cards,  etc.,  are  kept.  When 
cards  are  incorrectly  or  incompletely  filled  out  the  district  inspector  or 
nurse  is  summoned  to  the  borough  office. 


COMPULSORY   NOTIFICATION   OF  TUBERCULOSIS  CASES       457 

All  cases  reported  as  living  in  other  boroughs  are  reported  daily  to 
the  office  of  the  borough  in  which  they  live.  When  a  patient  moves  to 
another  borough  all  cards  and  records  of  the  case  are  forwarded  to  the 
office  of  that  borough. 

Inspectors  report  at  the  borough  office  every  Monday  at  9.30  a.m., 
bringing  with  them  all  cards,  etc.,  in  their  possession,  to  be  compared 
with  tally  index.  All  inspections  are  made  within  three  days.  Special 
assignments  (forcible  removals,  diagnoses  of  suspected  cases,  •etc.)  are 
attended  to  immediately.  Every  enti'y  on  back  of  blue  record  card  is 
dated.  An  observation  card  is  made  out  for  every  case  seen,  whether 
tubercular  or  not,  and  the  result  of  physical  examination  written  in  space 
"  present  condition." 

In  ordering  fumigation  the  date  on  which  it  is  to  be  done  is  always 
given  on  the  card.  Unless  the  premises  are  in  very  bad  condition  it  is 
usually  sufficient  to  renovate  the  room  occupied  by  the  patient  and  to 
fumigate  the  rest  of  the  apartment.  Where  the  entire  premises  are  prob- 
ably infected,  renovation  should  be  complete.  In  cases  where  the  premises 
are  in  very  good  condition,  fumigation  of  the  room  occupied  by  the  patient 
may  be  all  that  is  necessary. 

Great  care  and  accuracy  are  necessary  in  recommending  the  kind  and 
amount  of  renovation  necessary,  both  for  the  sake  of  justice  to  the  owner 
and  because  an  error  means  a  reinspection,  probably  rescindment  of  the 
order  for  renovation,  and  the  submitting  of  a  new  complaint.  The  floor 
and  position  of  the  premises  are  always  noted  on  the  blue  card,  complaint, 
fumigation  card,  etc.  The  full  name  of  the  owner  or  agent  is  given  in 
complaint;  if  it  cannot  be  obtained,  the  fact  is  stated.  All  cards  and 
reports,  without  exception,  are  mailed  on  the  day  the  inspection  is  made. 
The  regular  blank  is  used  for  all  reports. 

To  explain  the  word  "  forcible  removal  "  it  must  be  said  that  the 
Department  of  Health,  having  police  powers,  can  remove  a  patient  to 
tlie  Riverside  Sanatorium  by  force,  if  necessary,  even  if  his  consent 
or  tliat  of  his  family  is  not  ol)tained,  when  in  tlie  opinion  of  the 
authorities  the  necessary  precautions  cannot  or  will  not  be  observed, 
or  when  others,  especially  cliildren,  are  exposed  through  him  to 
tuberculosis. 

It  may  be  interesting  to  know  something  of  the  ultimate  behavior 
of  patients  under  such  enforced  removal.  The  writer  has  been  tlie  senior 
attending  physician  ever  since  the  institution  was  opened  live  years  ago, 
and  vouclies  for  the  fact  that  in  nearly  every  instance  the  patient,  hav- 
ing usually  l)een  removed  from  a  dark,  dreary,  overcrowded  tenement, 
from  an  unclean  room  and  bed,  where  very  often  he  had  insufficient 
nourishment,  into  a  clean  bed  in  a  briglit,  cheery,  airy,  and  well- 
ventilated  ward  of  the  Riverside  institution,  where  he  receives 
plenty  of  good  I'ood  and  considerate  treatment,  was  glad  to  remain. 
31 


458    PUBLIC  MEASURES  IN  THE   PROPHYLAXIS  OF  TUBERCULOSIS 

In  l)nt  two  instances  was  dissatisfaction  sho'ivn   or  an   attempt  made 
to  escape. 

Compulsory  Registration  in  the  United  States  Considered  by  a  Lay- 
man.— The  compulsory  reporting  and  registration  of  tuberculous  cases 
in  the  United  States  has  been  made  the  subject  of  a  careful  study  by 
Mr.  William  H.  Baldwin  ('06),  of  Washington,  D.  C,  a  layman,  but 
deeply  interested  in  the  problem,  and  a  director  of  the  National  Asso- 
ciation for  the  Study  and  Prevention  of  Tuberculosis.  From  his  admir- 
able article  on  this  subject  (New  Yorl-  Medical  Journal  of  December  8, 
1906)  are  reproduced  tables  giving  the  jjresent  status  of  compulsory 
registration  of  tuberculosis  in  the  United  States  and  some  of  Mr.  Bald- 
win's personal  comments : 

Since  tuberculosis  is  known  to  be  an  infectious  and  communicable  dis- 
ease, it  might  be  expected  that  the  first  step  to  be  taken  toward  controlling 
it  would  be  to  require  each  case  to  be  promptly  reported  to  the  proper 
authorities,  as  is  done  with  other  communicable  diseases;  but  when  this 
course  was  first  proposed  it  met  with  many  objections,  due  partly  to  the 
lack  of  knowledge  among  the  public  as  to  the  nature  of  the  disease  and 
partly  to  the  fact  that  it  differs  in  some  important  respects  from  other 
communicable  diseases. 

These  objections  came  mostly  from  physicians,  who  are  naturally  con- 
servative, and  who  opposed  such  reports  on  the  ground  that  they  inter- 
fered with  the  confidential  relations  of  patient  and  physician;  that  they 
would  be  made  public,  and  so  cause  patients  to  leave  physicians  who  made 
such  reports  and  go  to  those  who  refused  to  make  them;  but  such  patients 
would  be  injured  in  various  Avays  by  allowing  others  to  know  they  had 
tuberculosis,  and  that  a  stigma  would  also  be  placed  on  the  family  in 
which  the  disease  existed. 

Experience  where  such  reports  are  made  has  shown  that  these  objec- 
tions are  not  well  founded;  and  in  order  to  bring  this  experience  up  to 
the  present  time  an  inquiry  was  made  in  the  last  part  of  1905  and  the 
first  part  of  190G  as  to  such  reports  in  all  cities  of  the  United  States  hav- 
ing, according  to  the  census  bureau,  a  population  of  48,000  or  more  in 
1903,  of  which  there  are  eighty-six.  The  health  department  or  board  of 
health  in  each  city  was  asked,  among  other  things: 

Whether  the  city  had  any  ordinance  or  regulation  requii-ing  the  report 
and  registration  of  all  eases  of  tuberculosis;  whether  or  not  such  reports 
were  kept  private  when  made;  whether  any  difficulty  was  experienced  in 
keeping  them  private;  whether  there  was  now  any  serious  objection  on 
the  part  of  physicians  to  making  such  reports. 

Eeplies  received  show  that  such  reports  are  required  in  53  cities  out 
of  the  86,  of  which  14  require  reports  of  all  forms,  16  of  pulmonai-y  only, 
and  23  did  not  state  whether  reports  of  other  forms  than  pulmonary  were 
required  or  not.     (See  Tables  1  and  2.) 


COMPULSORY   REGISTRATION   IN  THE   UNITED   STATES       459 


Table  1. — Cities  hiiving  Compulsory  Law  for  Reports  and  Registration  of  Cases  oj 
Tuberculosis,  ivilh  Population  and  Date  of  the  Passage  of  Such  Law  in  Chrono- 
logical Order. 


t'lTV. 


New  York 

Camden,  N.  J 

Cincinnati,  Ohi.) 

Elizabeth,  N.  J 

Boston,  Mass 

Buffalo,  N.  Y 

Rochester,  N.  Y 

Trenton,  N.  J 

Bridgeport,  Conn 

Lowell.  Mass 

Worcester,  Mass 

Louisville,  Ky 

Atlanta,  Ga 

Oakland,  Cal 

Providence,  R.  I 

Hartford,  Conn 

Cambridge,  Mass 

Omaha,  Neb 

San  Francisco.  Cal ... . 

Los  Angeles,  Cal 

Memphis,  Tenn 

St.  Paul,  Minn 

Minneapolis,  Minn 

Reading,  Pa 

Somerville.  Mass 

*Des  Moines,  la 

Springfield,  Mass 

Cleveland,  Ohio 

Youngstown,  Ohio. . .  . 

Yonkers,  N.  Y 

Paterson,  N.  J 

*Salt  Lake  City,  I'tah. 
Grand  Rapids,  Mich . . . 

St.  Louis,  Mo 

♦Baltimore,  Md 

fPhiladelphia.  Pa.  .    . 
New  Haven,  Conn.    . . . 

fMilwaukee.  Wis 

Fall  River,  Mass 

Waterl:)ury,  Conn 

tPittsburg,  Pa 

New  Bedford,  Mass.  . . 

Columbus,  Ohio 

Erie,  Pa 

Chicago,  III 

Lawrence,  Mass 

Peoria,  III 

Detroit,  Mich 

Holyoke.  Mass 

Seattle,  Wash 

Wilkesbarre,  Pa 

Troy,  N.  Y 

Indianapolis,  Ind 


Population, 
Census  1900. 


,437,202 

75,935 

325,902 

52,130 

560,892 

352,387 

162,608 

73,307 

70.996 

94,969 

118,421 

204,731 

89.872 

66,960 

175,597 

79.850 

91,886 

102,555 

342,782 

102,479 

102,320 

163,065 

202,718 

78,961 

61,643 

62,1.39 

62,059 

381,768 

44,885 

47,931 

105,171 

53,531 

87,565 

575,238 

508,957 

,293,697 

108,027 

285,315 

104.863 

45,859 

321,616 

62,442 

125,560 

52,733 

,698,575 

62,559 

56,100 

285,704 

45,712 

80,671 

51,721 

60,651 

169,164 


Date  of  Law. 


January  18.  1897. 
December  27,  1897. 
August  19,  1898. 
March  6,  1.S99. 
May  1.  1900. 
1900. 
1900. 

January  8.  1901. 
April  23.  1902. 
September,  1902. 
October  8,  1902. 
October,  1902. 
October,  1902. 
1902. 

Januarv  15.  1903. 
March  4,  1903. 
March  11,  1903. 
June  30,  1903. 
October  27.  1903. 
October,  1903. 
1903. 

January,  1904. 
August  26,  1904. 
September  1.  1904. 
October  6.  1904. 
October  28.  1904. 
November  1,  1904. 
February  3,  1905. 
February  6,  1905. 
February,  1905. 
March  3,  1905. 
March  9.  1905. 
March.  1905. 
April  7.  1905. 
April  8.  1905. 
April  27,  1905. 
April,  1905. 
May  15.  1905. 
June  13,  1905. 
September  5.  1905. 
September  10,  1905. 
November  8,  1905. 
1905. 

January  1,  1906. 
January  1,  1906. 
February  19.  1906. 
February  20,  1906. 


*  State  law.         f  Slate  law;  enforcement  in  this  cily  began  at  about  this  time. 


460    PUBLIC  MEASURES  IN  THE   PROPHYLAXIS  OF  TUBERCULOSIS 


Table  2. — Cities  which  do  not  have  Compulsory  Report  Laws  for  Reports  of   Cases 

of   Tuberculosis 


City. 

Population, 
Census    1900. 

City. 

Population, 
Census  1900. 

New  Orleans,  La 287,104 

Lynn,  Mass 

68,513 

Washington,  D.  C 278,718 

Savannah,  Ga '. 

54,244 

Newark,  N.J 246,070 

Jersey  City,  N.J 206.433 

Hoboken,  N.  J 

Evansville,  Ind 

59,364 
59,007 
56,987 
56,383 
51,418 
53,321 
52,969 

Kansas  City,  Mo 

Denver,  Colo 

Toledo,  Ohio 

Allegheny,  Pa 

Syracuse,  N.  Y 

St.  Joseph,  Mo 

Scran ton.  Pa 

Portland,  Ore 

Albany,  N.  Y 

Dayton,  Ohio 

Richmond,  Va 

Nashville,  Tenn 

Wilmington,  Del 

163,752 

133.859 

131,822 

129,896 

108,374 

102,979 

102,026 

90,426 

94,151 

85,333 

85.050 

80,865 

76,508 

Manchester,  N.  II 

Utica,.N.  Y 

Kansas  City,  Kan 

San  Antonio,  Te\ 

Duluth,  Minn 

Charleston,  S.  C 

Norfolk,  Va 

Harrisburg,  Pa 

Portland,  Me 

Houston,  Tex 

55,807 
46.624 
50,167 
50,145 
44,633 

Schenectady,  N.  Y 

Fort  Wayne,  Ind 

31,682 
45,115 

In  six  cases  the  date  when  the  law  was  passed  was  not  given,  but  in 
the  others  it  took  effect  as  follows : 


Year. 

Cities. 

Year. 

Cities. 

1897 

1898 

2 
1 

1 
3 

1 

1902 

1903 

6 

7 

1899                 

1904 

1905 

Three  months  of  1906 

6 

1900 

1901 

17 
3 

This  shows  a  decided  awakening  to  the  necessity  of  such  reports. 

The  total  population  of  these  eighty-six  cities  by  the  census  of  1900 
was  17,270,126,  nearly  one  quarter  of  the  population  of  the  United  States. 
The  fifty-three  which  require  reports  had  a  population  of  14,030,381,  or 
81.2  per  cent,  while  those  not  yet  having  such  a  law  contained  3,239,745, 
or  18.8  per  cent. 

In  the  large  cities  this  proportion  is  still  greater,  for  of  the  twenty 
largest  cities,  sixteen,  containing  10,953,081,  or  91.5  per  cent,  have  such 
a  law,  and  four,  with  1,018,325,  or  8.5  per  cent,  do  not;  so  that  consider- 
ably less  than  one  tenth  of  the  population  in  the  twenty  largest  cities  do 
not  have  this  regulation,  and  such  reports  are  required  in  all  the  thirteen 
largest. 

As  to  privacy,  nine  cities  do  not  state  whether  the  reports  are  kept 
private  or  not,  two  say  that  no  one  has  asked  to  see  them,  seven  that  the 
reports  are  kept  private,  and  thirty-one  that  they  are  "  kept  private  with- 
out difficulty  " ;  while  in  only  three — Seattle,  Des  Moines,  and  Wilkes- 
barre — it  is  stated  that  the  reports  are  open  to  the  public.     This  furnishes 


COMPULSORY  REGISTRATION   IN  THE   UNITED   STATES       461 

conclusive  proof  that  such  reports  can  be  kept  private,  as  they  should  be, 
and  that  the  objection  of  harm  to  the  patient  or  his  family  by  reason  of 
publicity  from  such  a  report  is  without  force. 

The  information  as  to  the  attitude  of  the  medical  profession  in  the 
different  cities  is  a  little  more  difficult  to  classify,  as  circumstances  vary, 
and,  as  the  dates  given  show,  the  laws  in  twenty  cities  have  been  in  exist- 
ence but  a  year  or  less,  and  in  some  were  apparently  not  yet  vigorously 
enforced;  but  the  substance  of  the  replies  was  as  follows: 

Cities  in  which  there  is  no  objection,  or  practically  none 34 

Cities  in  which  there  is  little  objection 11 

Cities  in  which  physicians  object 5 

Cities  which  do  not  state 3 

Total 53 

One  of  the  cities  objecting  is  Detroit,  Mich.,  where  an  attempt  to 
enforce  the  penalty  resulted  in  a  lawsuit,  which  was  carried  to  the  Su- 
preme Court  of  the  State  and  was  not  decided  at  last  accounts.  Pend- 
ing this  no  attempt  is  made  to  enforce  the  ordinance,  which  still  stands. 
It  is  apparent,  however,  that  opposition  is  decreasing  with  the  increase  of 
knowledge  on  the  subject,  and  in  New  York  City,  where  the  law  has  had 
the  longest  and  most  thorough  trial,  it  is  said  that  there  is  now  "  no 
objection  whatever."  The  records  show  that  in  more  than  ninety  per  cent 
of  all  deaths  from  tuberculosis  in  that  city  the  case  has  been  previously 
reported  to  the  health  department. 

In  many  of  the  cities  it  is  difficult  to  determine  from  the  replies  just 
what  proportion  of  all  cases  is  reported.  Some  cities  are  evidently  lax 
in  the  enforcement  of  the  law,  but  the  greater  number  make  an  honest 
effort  to  secure  reports  of  all  cases,  and  one  declares  that,  so  far  as  is 
known,  they  get  them  all.  The  results  indicate  an  increasing  efficiency 
on  the  part  of  the  authorities  commensurate  with  the  growing  interest  in 
the  subject. 

The  laws  differ  somewhat  as  to  the  action  to  be  taken  by  the  health 
authorities  when  a  case  is  reported,  but  many  of  them  follow  very  closely 
the  course  of  procedure  in  New  York  City.  In  case  the  attending  physi- 
cian requests  that  no  action  be  taken,  nothing  is  done  except  to  record 
the  case,  as  it  is  not  intended  to  interfere  in  the  relations  of  physician 
and  patient  where  the  physician  assumes  the  responsibility.  If,  however, 
the  case  is  in  a  tenement  house  where  close  contact  endangers  other  peo- 
ple, or  if  the  physician  does  not  request  that  nothing  be  done,  the  health 
department  inspects  the  place  and  takes  pains  to  see  that  proper  sanitary 
rules  are  observed,  and  that  the  patient  and  others  are  informed  as  to 
what  precautions  are  to  be  taken  to  prevent  infection.  If  the  patient  is 
unable  of  himself  to  secure  proper  food  or  proper  nursing,  measures  are 
taken  to  provide  the  necessary  care  and  nourishment.  A  report  of  the 
removal  of  any  patient  to  another  dwelling  is  required,  and  upon  such 
removal,  or  upon  the  death  of  the  patient,  disinfection  of  the  premises 
is  insisted  on. 


462    PUBLIC   MEASl'RES  IN   THE   PROPHYLAXIS   OF   TUBERCULOSIS 

Enforced  in  this  manner,  with  due  regard  to  the  relation  of  the  physi- 
cian who  assumes  the  responsibility  in  all  private  cases,  but  supplement- 
ing and  making  up  for  any  lack  of  medical  attention  or  any  carelessness 
where  others  are  endangered,  it  has  been  found  that  there  is  no  reasonable 
objection  to  such  a  regulation.  Dr.  Hermann  M.  Biggs,  who  for  years 
has  been  the  chief  medical  officer  of  the  Department  of  Health  of  Kew 
York  City,  says: 

"  The  notification  of  a  case  of  tuberculosis  does  not  require  any  action 
on  the  part  of  the  authorities,  if  it  seems  reasonable  to  assume  that  such 
action  is- unnecessary.  The  very  fact  that  tuberculosis  is  notified  by  the 
attending  physician  as  a  communicable  disease  has  the  greatest  educa- 
tional value,  and  justifies  the  assumption  in  those  instances  in  which  the 
case  is  under  the  supervision  of  a  private  physician  that  reasonable  and 
necessaiy  precautions  for  the  protection  of  others  will  be  taken. 

"...  Experience  has  shown  that  the  obstacles  are  largely  imaginary; 
that  the  harmful  results  which  were  predicted  as  certain  to  follow  have 
failed  to  materialize." — Medical  News,  Februarj^  20,  1904. 

It  is  because  of  this  extended  experience  in  ICew  York  City,  which  is 
confirmed  by  that  of  other  cities  which  have  since  adopted  similar  laws, 
that  the  sentiment  in  favor  of  such  regulations  in  the  cities  of  the  United 
States  is  growing  so  rapidly. 

In  this  inquiry  but  two  instances  were  found  in  which  any  hard- 
ship had  been  suffered  by  the  patient  on  account  of  lack  of  judgment 
on  the  part  of  inspectors  of  the  health  department,  but  in  order  to 
I^revent  this  it  is  important  that  the  law  be  worded  properly.  From  a 
study  of  all  laws  obtained  from  the  different  cities,  Mr.  Baldwin  sug- 
gests a  hill  which  should  be  suljmitted  for  tlie  passage  in  sucli  State 
legislatures  which  have  not  yet  any  provision  for  compulsory  notification 
of  tuberculosis  cases.  (This  bill  is  reproduced  in  the  Appendix,  p.  811, 
as  it  may  serve  as  a  guide  to  physicians  desiring  to  promulgate  such  a 
law  in  their  respective  States.) 

Mr.  Baldwin  concluded  his  very  instructive  article  with  the  follow- 
ing significant  phrase : 

From  all  this  it  will  be  seen  that  the  growing  knowledge  of  the  nature 
of  tuberculosis,  and  the  increasing  interest  taken  in  the  subject,  are  hav- 
ing their  influence  in  adding  to  the  number  of  cities  requiring  compulsory 
reports  and  registration  of  all  cases  of  tuberculosis,  and  that  the  wisdom 
of  what  is  logically  the  first  step  to  be  taken  in  the  control  of  the  disease 
is  confirmed  by  experience,  where  it  has  been  attempted  in  the  proper 
manner. 

All  communications  referring  to  a  patient's  disease,  in  which  his 
name  and  address  are  given,  should  be  made  in  closed  letters  and  never 
sent  by  postal  card.    A  number  of  health  boards  use  postal  cards  giving 


CARE   OF   TrBERClLOrS   INSANE  463 

full  name  and  address  and  stating  whether  a  small  or  large  nuinl)er  or 
no  bacilli  have  been  found.  In  small  communities,  as  well  as  in  large 
ones,  such  open  communications  may  prove  disastrous  to  the  unfor- 
tunate patient  concerning  whom  the  report  has  been  made. 

Care  of  Tuberculous  Federal  Employees. — The  care  of  the  tuber- 
culous must,  of  course,  also  include  the  tuberculous  individuals  in  the 
army  and  navy,  and  other  tul^erculous  government  employees,  inmates 
of  prisons,  reformatories,  insane  asylums,  etc.  The  tuberculous  sailors 
of  the  United  States  Marine  Hospital  Service  are  taken  care  of  at  Fort 
Stanton,  N.  M.,  the  tuberculous  men  of  the  United  States  Navy  are 
sent  to  the  United  States  Naval  Hospital  at  New  Fort  Lyon,  Col.,  and 
the  tuberculous  soldiers  are  cared  for  at  Fort  Bayard,  X.  M.,  now  trans- 
formed into  a  sanatorium. 

To  assure  a  timely  diagnosis  in  the  cases  of  our  sailors  and  soldiers 
the  writer  would  suggest  a  periodical  examination,  at  least  every  six 
months,  of  the  chest  of  every  soldier  and  sailor.  Only  by  such  methods 
will  it  be  possible  to  weed  out  from  the  barracks  or  the  war  ships  the 
tuberculous  individuals  and  give  them  the  best  possible  chance  for  an 
early  recovery. 

President  Eoosevelt  issued  the  first  executive  order  with  a  view  to 
preventing  the  spread  of  tuberculosis  among  the  employees  of  the  Gov- 
ernment (especially  of  post  offices)  in  February,  1906.  The  recent 
discovery  of  tive  cases  of  tuberculosis  among  the  employees  of  the 
Insular  Bureau  of  the  War  Department  in  the  State,  War,  and  Navy 
Building,  seems  to  indicate  the  necessity  of  such  periodic  examina- 
tions of  all  government  employees,  in  order  that  these  patients  may 
be  treated  at  the  right  time  and  in  the  right  place  and  before  it  is 
too  late. 

Care  of  Tuberculous  Insane. — Dr.  A.  E.  McDonald,  Director  of  the 
Manhattan  State  Hospital  for  the  Insane  for  the  Directory  of  Institu- 
tions and  Societies  Dealing  with  Tuberculosis  in  the  United  States, 
says,  in  part: 

It  is  not  proposed  to  follow  here  in  detail  the  history  of  tbe  oamp  for 
tuberculous  patients.  Neither  the  purpose  of  this  communication  nor  the 
limitation  as  to  space  will  permit  of  it,  and  the  reader  who  may  desire 
further  information  in  that  direction  must  be  referred  to  the  annual 
printed  reports  of  the  hospital  and  to  special  articles  by  members  of  the 
hospital  staff  which  have,  from  time  to  time,  appeared  in  the  Journal 
of  Insanity  and  other  professional  publications.  It  must  suffice  to  sum- 
marize results.  The  isolation  of  the  tuberculous  patients  has  reduced  to 
a  minimum  the  danger  of  infection  of  other  patients  and  of  employees. 
The  patients  themselves  have  suffered  no  injury  or  hardship,  but  have, 
on  the  contrary,  been  unmistakably  benefited.    This  is  shown,  among  other 


464    PUBLIC  MEASURES  IN  THE   PROPHYLAXIS  OF  TUBERCULOSIS 

ways,  by  the  decrease  in  the  death-rate  from  pulmonary  tuberculosis,  both 
absolute  and  relative,  and  bj'  a  marked  general  increase  in  bodily  weight, 
amounting  in  the  case  of  one  patient  to  an  actual  doubling  of  weight — 
from  83  to  166  pounds — in  fourteen  months  of  camp  residence. 

Mental  improvement  has,  as  a  general  rule,  been  the  concomitant  of 
the  physical,  not  only  among  the  patients  in  the  Tuberculosis  Camp,  but 
also  in  the  others,  and  in  the  former  class  this  has  been  somewhat  of  an 
anomaly.  My  experience,  and  I  think  that  of  others,  has  been  that  when 
phthisis  and  insanity  coexist  they  are  apt  to  alternate  as  to  the  promi- 
nence of  their  several  manifestations — the  mental  symptoms  being  more 
pronounced  while  the  physical  are  in  abeyance,  and  vice  versa.  Under 
the  tent  treatment  we  have  found  a  general  disposition  toward  accord  in 
the  manifestations,  improvement  in  both  respects  proceeding  concurrently, 
and  some  of  the  discharges  from  the  hospitals  which  gave  most  satisfac- 
tion to  us  at  the  time,  and  most  assurance  for  the  patient's  future,  were 
of  inmates  of  the  Tuberculosis  Camp. 

The  mental  improvement,  even  in  cases  where  recovery  was  not  to  be 
looked  for,  has  been  a  gratifying  feature  of  the  camp  experiment,  and 
depending  largely,  as  it  has,  upon  the  patient's  satisfaction  with  his  new 
surroundings,  has  served  to  dispel  one  of  the  doubts  with  which  the  ex- 
periment was  undertaken.  It  was  apprehended  that  not  only  might  the 
patients  themselves  resent  their  transfer,  but  that  similar  objection  might 
come  from  their  relatives  and  friends,  since  innovations,  even  progressive 
ones,  are  apt  to  be  frowned  upon  by  those  who  constitute  the  majority 
of  the  clientele  of  a  public  hospital  in  a  cosmopolitan  city.  Even  at  the 
outset,  however,  the  protests,  whether  from  patients  or  their  friends,  were 
surprisingly  few,  and  latterly  they  have  been  more  apt  to  arise,  if  at  all, 
over  the  patient's  return  to  the  buildings  when  that  becomes  necessary. 

As  an  interesting  incidental  fact  it  may  be  mentioned  that  not  only 
the  patients,  but  also  the  nurses,  living  in  the  camp  have  enjoyed  almost 
complete  immunity  from  other  pulmonary  diseases.  Not  a  single  case  of 
pneumonia  has  developed  in  the  camp  in  its  existence  of  over  three  years, 
though  it  caused  131  deaths  in  the  hospital  proper  in  that  time.  The 
"  common  colds  "  so  frequent  among  their  fellows  living  upon  the  wards, 
or  in  the  Attendants'  Home,  have  been  unknown  among  the  tent  dwellers. 

The  popular  idea  that  the  consumptive  is  a  doomed  man  unless  he  can 
at  once  abandon  home  and  family  and  business,  and  betake  himself  to 
some  remote  region,  would  seem  to  be  negatived  by  our  Ward's  Island 
experience.  So  also  with  the  strenuous  claims  for  high  altitude.  The 
Ward's  Island  Camp  is  but  a  few  feet  above  the  tidewater  level,  its  side 
is  swept  in  winter  by  winds  of  high  velocity  coming  over  the  ice-bound 
waters  of  the  rivers  and  the  Sound  Avhich  surround  it,  and  it  suffers  as 
much  as,  or  more  than,  any  other  part  of  the  city  of  New  York  from  the 
trying  changes  of  temperature  and  humidity  which  are  so  characteristic 
of  its  climate.  If,  in  spite  of  all  these  drawbacks,  what  has  been  done 
can  be  done,  and  that  for  insane  patients,  what  may  not  be  hoped  from 
the  extension  of  the  same  methods  to  the  ordinary  consumptive  of  sound 


TUBERCULOSIS  IN   PRISONS  AND   REFORMATORIES  465 

mind,   anxious  for  recovery  and  capable   of  giving  intelligent   assistance 
in  the  struggle? 

Care  of  the  Tuberculous  in  Almshouses,  Asylums,  and  Boarding 
Schools. — Asylums  for  the  aged  and  crippled,  poorhouses,  orphan  asy- 
lums, and  hoarding  schools  are  very  often  the  seat  of  numerous  early 
cases  of  tuberculosis,  which,  because  of  a  belated  diagnosis,  finally  be- 
come centers  of  infection.  In  all  such  institutions  sanitary  supervision 
as  to  proper  ventilation  and  periodical  examination  of  the  inmates' 
chests  will  be  the  only  means  to  do  away  with  this  danger. 

Tuberculosis  in  Prisons  and  Reformatories. — Tuberculosis  in  prisons 
and  reformatories  is  a  suljject  of  vital  importance  in  a  crusade  against 
this  disease.  It  was  the  writer's  privilege  last  year,  on  invitation  of  the 
physicians  of  the  National  Prison  Congress,  to  address  that  gathering 
on  the  subject  of  "  The  Tuberculosis  Problem  in  Prisons  and  Reforma- 
tories." It  would  seem,  thus,  that  the  medical  men  in  charge  of  these 
institutions  are  fully  aware  of  the  importance  of  the  subject.  Yet  only 
a  few  States  have  made  an  effort  to  separate  the  tuberculous  prisoners 
from  the  nontuberculous,  and  fewer  yet  have  undertaken  systematically 
to  treat  them.  It  is  hoped  that  State  governments  will  soon  act  on  the 
suggestions  of  the  prison  physicians,  who  are  almost  unanimous  as  to  the 
necessity  of  segregating  and  treating  the  tuberculous  inmates  in  prisons. 

In  the  address  above  referred  to  (Knopf,  'Ofi)  a  plea  was  made  not 
only  for  the  examination  of  every  prisoner  committed  to  a  penal  insti- 
tution at  the  time  of  his  entrance,  and  periodically  afterwards,  but  also 
for  examination  of  individuals  in  detention  prisons.  As  far  as  could  be 
learned  from  visits  to  detention  prisons  in  New  York  and  other  States, 
prisoners  who  are  simply  held  for  trial  or  are  awaiting  removal  to 
the  penitentiary,  are  never  examined  by  any  physician  unless  they  are 
quite  ill  and  in  actual  need  of  medical  attention,  or  obviously  af- 
flicted with  consumption.  It  must  be  evident  that  in  this  way  a  latent 
tuberculosis  has  a  chance  to  develop,  for  even  in  the  better  city  prisons 
the  usual  overcrowding  will  render  the  atmosphere  vitiated,  particularly 
in  winter.  Add  to  this  the  lack  of  exercise  and  the  depressing  psychical 
influence  of  confinement,  nostalgia,  and  worry,  one  cannot  wonder  that 
prisoners  arriving,  after  sentence,  at  a  penal  institution  are  often  found 
to  be  tuberculous,  some  even  with  very  active  lesions,  while  they  may 
have  entered  the  prison  of  detention  seemingly  in  good  health.  Again, 
some  may  have  been  a  little  below  par,  underfed  or  weakened  by  expo- 
sure, and  as  a  result  have  contracted  tuberculosis  from  consumptive 
fellow  prisoners  while  in  jail. 

This  is  not  said  in  disparagement  of  the  heroic  attempts  made  by 
most  of  the  wardens  and  physicians  to  render  modern  detention  prisons 


466    PUBLIC   MEASURES   IN   THE    PROPHYLAXIS   OF   TUBERCULOSIS 

as  sanitary  as  possible.  A  good  example  is  the  well-kept  and  modernly 
built  principal  prison  of  New  York,  The  Tombs,  situated  on  Center 
Street,  between  Leonard  and  Franklin  Streets.  But  even  here  one 
strongly  predisposed  or  already  slightly  atBicted  with  pulmonary  tuber- 
culosis has  a  good  chance  to  develop  the  disease  to  its  full  extent.  It 
is  impossible,  with  400  prisoners  comprising  the  ever-changing  prison 
population  of  the  Tombs,  that  one  single  physician  could  examine  all 
prisoners  carefully  enough  to  detect  the  presence  of  an  incipient  tuber- 
culosis. Prisoners  awaiting  trial  stay  in  the  Tombs  sometimes  six 
months  and  longer.  They  are  not  occupied  with  anything.  They  are 
allowed  to  exercise  in  the  open  air  only  once  a  week  and  for  a])out  an 
hour  and  a  half.  It  is  well  known  that  many  detention  prisons  are  not 
as  hygienically  built  as  this  one,  and  that  there  exist  additional  depress- 
ing factors  in  many  of  them  well  calculated  to  further  tuberculous 
diseases. 

What  can  be  done  to  strike  at  the  root  of  this  deficiency  in  dealing 
with  the  tuberculosis  problem  in  prisons?  A  competent  staff  of  expert 
diagnosticians  should  he  attached  to  every  detention  prison  to  examine 
each  prisoner  for  tuberculosis,  syphilis,  or  other  infectious  diseases.  The 
seeming  increase  of  expense  which  would  thus  arise  to  the  community 
will  in  the  end  result  in  a  financial  and  sanitary  benefit  to  the  com- 
munity at  large.  Nor  is  there  any  reason  wiiy  the  prisoner  who  has 
means  should  not  be  taxed  to  defray  the  expense  for  a  measure  from 
which  he  himself  derives  the  greatest  benefit.  If  he  is  himself  unknow- 
ingly afilictcd  with  tuberculosis,  the  early  recognition  may  mean  to  him 
the  saving  of  his  life.  If  the  disease  is  recognized  in  one  of  his  fellow 
prisoners  he  is  protected  from  contracting  it. 

If  prisoners  did  have  to  remain  in  detention  prisons  only  three 
or  four  weeks,  the  enforced  idleness  with  one  hour  and  a  half  open-air 
exercise  weekly  miglit  not  be  very  injurious;  but  when  tlieir  time  of 
staying  in  the  detention  prison  is  longer  than  that,  a  physical,  mental, 
and  moral  deterioration  is  almost  inevitable. 

It  is  at  the  very  beginning  of  incarceration  and  enforced  idleness 
that  these  factors  produce  the  most  depressing  effects,  and  if  there  is 
any  predisposition  to  tuberculosis  it  is  sure  to  develop  it.  Whenever 
practicable,  even  detention  prisoners  should  be  occupied  with  something 
useful  and  health-sustaining. 

Lastly,  there  should  be  some  arrangement  in  the  detention  prison  to 
give  the  prisoner  a  sufficient  amount  of  exercise  in  the  open  prison 
court  to  assure  his  physical  well-being — not  weekly,  but  daily. 

It  would  thus  seem  that  the  first  step  toward  the  prevention  of 
tuberculosis  in  penal  institutions  should  be  a  most  careful  examina- 
tion of  such  individuals,  and  the  weeding  out  and  isolating  of  all  tuber- 


TUBERCULOSIS   IN   PRISONS  AND   REFORMATORIES  467 

culous  prisoners  detained  in  jails.  The  tuberculous  patient  should 
remain  isolated  in  the  detention  prison  as  well  as  in  the  penal  institu- 
tion, and  he  should  bo  given  the  benefit  of  hygienic  and  dietetic  treat- 
ment from  the  first  moment  he  becomes  a  ward  of  the  State  or  city. 

When  the  time  for  his  transfer  comes,  the  history  card  of  his  disease 
and  the  recommendation  of  the  physician  should  be  transmitted  Avith 
the  other  papers  of  the  prisoner  to  the  penal  institution.  After  his 
arrival  at  the  prison,  in  which  he  is  to  stay  for  some  length  of  time, 
the  physician  will  decide  whether  he  is  al)le  to  work  or  not,  and  wliat 
kind  of  work  might  be  most  conducive  to  his  recovery.  There  is  no 
gainsaying  that  the  ideal  occupation  for  the  tuberculous  prisoner  is  agri- 
cultural or  garden  work. 

In  a  previous  communication  on  prison  hygiene  as  far  as  it  apper- 
tains to  the  prevention  of  tuberculosis,  the  writer  stated  that  not  only 
should  there  be  a  careful  examination  of  every  prisoner  for  tuberculosis 
when  he  enters  the  prison  of  detention  or  the  penal  institution,  but  his 
chest  should  be  reexamined  periodical!}^,  at  least  once  every  three  months. 
With  this  periodic  examination  a  very  incipient  case,  which  might  have 
escaped  detection  during  the  "  entrance "  examination,  is  sure  to  be 
discovered  before  the  disease  has  progressed  to  any  considerable  extent. 

Expectorating,  except  in  proper  receptacles  placed  for  that  purpose 
in  cells,  workshops,  chapels,  schools,  and  on  the  grounds,  should  be 
punished  by  severe  disciplinary  measures.  That  there  may  never  be 
an  excuse  for  violating  this  rule,  there  should  be  provided  not  only  a 
sufficient  number  of  fixed,  elevated,  suspended,  simple,  or  self-flushing 
cuspidors  as,  or  similar  to,  the  ones  illustrated  in  the  Appendix,  but 
each  prisoner  should  carry  some  sort  of  a  pocket  flask  or  receptacle 
made  of  metal,  glass,  or  pasteboard,  similar  to  those  used  in  sanatoria 
for  consumptives. 

A  prison  is,  perhaps,  the  only  place  in  the  world  where  spitting 
regulations  can  be  rigorously  enforced,  and  it  is  but  fair  that,  if  we 
say  to  an  individual,  "  Don't  spit  here  and  don't  spit  there,"  we  should 
give  him  a  chance  to  spit  somewhere  when  he  has  an  excess  of  saliva, 
a  cold,  etc.  With  such  a  measure  not  only  would  tuberculosis  diminish 
in  prisons,  but  epidemics  of  pneumonia  and  grip  would  be  less  to  bo 
feared  and  more  easily  controlled.  It  might  be  recommended  as  a  regu- 
lation that  every  prisoner  must  hold  his  hand  before  his  mouth  when 
coughing,  whether  this  coughing  spell  is  followed  by  expectoration  or 
not.  Thus  drop-infection — that  is  to  say,  the  expulsion  of  bacilli  with 
droplets  of  saliva — will  l)e  avoided,  and  since  the  pneumococcus  is  so 
very  prevalent,  even  in  the  mouths  of  healthy  individuals,  this  precau- 
tion may  perhaps  also  tend  to  the  diminution  of  pneumonia.  As  an 
additional  measure  to  prevent  drop-infection,  it  might  be  well  never  to 


468    PUBLIC   MEASURES  IN  THE  PROPHYLAXIS  OF  TUBERCULOSIS 

put  prisoners  too  close  together  at  the  work  tables.  Whenever  prac- 
ticable, there  should  be  a  distance  of  three  feet  between  them.  It  has 
been  demonstrated  that  at  that  distance  the  droplets  expelled  during 
coughing  fall  to  the  ground. 

It  goes  without  saying  that  the  personal  and  l)ed  linen  of  the  tuber- 
culous prisoner  as  well  as  his  clothing  should  be  subjected  to  disinfec- 
tion regularly.  The  handkerchiefs  of  this  class  of  prisoners  should  con- 
sist of  squares  of  cheap  muslin,  which  should  be  burned  after  use. 

To  judge  from  the  appearance  of  the  various  kinds  of  blankets, 
comforters,  and  quilts  which  were  lying  on  the  cots  in  the  prisoners' 
cells  in  some  of  tlie  penitentiaries  visited  by  the  writer,  it  seemed  that 
these  coverings  might  become  the  means  of  spreading  infection,  not  only 
of  tuberculosis,  but  of  a  good  many  other  communicable  and  contagious 
diseases.  The  blankets  and  comforters  are,  as  a  rule,  the  private  prop- 
erty of  the  prison  inmate.  He  brings  these  articles  with  him,  or  they 
are  given  to  him  by  visiting  friends,  or  by  fellow  prisoners  who  have 
been  discharged.  In  most  prisons  these  coverings,  as  well  as  the  cloth- 
ing which  the  prisoner  wears  on  entering  the  penal  institution,  are 
carefully  disinfected.  The  precaution  does  not,  however,  suffice  to  pre- 
vent the  bed  covering  from  becoming  thoroughly  infected  afterwards, 
particularly  with  the  germs  of  tuberculosis.  Pulmonary  tuberculosis 
is  so  insidious  in  the  early  stages  that  the  prisoner  may  have  infected 
his  bedclothing  long  before  his  disease  was  discovered  by  the  ])rison 
physician,  unless,  of  course,  frequent  and  thorough  examinations  of  all 
prisoners  are  in  vogue. 

To  guard  against  infection  which  may  arise  from  blankets,  com- 
forters, etc.,  having  been  soiled  by  tuberculous  sputum  or  other  infec- 
tious material,  the  writer  would  suggest  that  after  thoroughly  disin- 
fecting these  articles  when  they  are  brougbt  to  tlie  j^jrison,  they  be 
incased  in  a  covering  of  light-colored  washable  material  (not  neces- 
sarily white),  as  one  uses  a  pillow  case.  By  basting  the  blanket  in  its 
"  blanket  case  "  it  can  be  manipulated  with  as  much  ease  as  if  uncovered. 
With  comforters  and  quilts  the  same  method  should  be  pursued.  There 
should  be  two  sets  of  cases,  so  that  the  blankets  need  not  remain  un- 
covered while  one  case  is  being  washed;  thus  the  blankets  need  never 
come  in  direct  contact  with  the  prisoner's  body.  With  such  a  system, 
and  with  the  injunction  that  this  washing  must  be  done  regularly,  one 
factor  of  transmitting  tuberculosis  and  other  infections  from  prisoner 
to  prisoner  will  be  done  away  with. 

Even  the  prisoner  who  is  only  suspected  of  having  tuberculosis 
should  have  a  separate  cell,  and,  as  far  as  possible,  the  placing  of  two 
prisoners  in  one  cell  should  be  avoided. 

The  bucket  system  for  receiving  the  dejecta  of  prisoners  during  the 


a  ^^ 


TUBERCl^LOSIS   IN   PRISONS  AND   REFORMATORIES  469 

night  and  during  the  day  when  confined  to  their  cells,  is  most  deplor- 
able. It  is  unsanitary  in  general,  and  as  far  as  it  permits  the  emana- 
tion of  odors  and  gases  it  is  deleterious  to  the  health  of  the  inmate. 
The  individual  cell  water-closet,  with  a  perfect  trap  and  cover,  such  as 
is  used,  for  example,  in  the  New  York  Tombs  and  other  new  prisons,  is 
certainly  to  be  recommended  in  place  of  the  bucket  system. 

The  more  advanced  cases  of  tuberculosis,  particularl}^  those  with 
constant  fever  and  in  whom  there  is  disintegration  and  corresponding 
abundant  expectoration  of  bacilli,  should  be  treated  in  special  wards, 
and  in  summer,  perhaps,  in  special  tents  of  the  prison  hospital. 

In  view  of  the  probable  indiflFerence  to  hygienic  regulations  of  the 
inmates  of  the  hospital,  and  for  the  purpose  of  preventing  drop-infec- 
tion, all  patients  in  the  more 
advanced  stages  must  wear  a 
mouth  mask.  Patients  in  a 
number  of  European  hospitals 
for  consumptives  are  told  to 
make  use  of  such  masks  in  or- 
der to  protect  themselves  as  well 
as  the  other  patients.  The 
mask  shown  in  Fig.  36  is  known 
as    Professor    Friinkel's    mouth 

mask.    It  is  a  valuable  means  to       t-,      .^^     t.  ^ 

,      -         •    J.     ,•  1-1  tiG.  136. — B.  Frankel's  Mouth  Mask  FOR 

prevent    drop-mfection,    which,  ^he  Prevention  of  Drop  Infection. 

with  the  advanced  cases  among 

consumptives,  is  quite  a  serious  factor  in  the  propagation  of  the  dis- 
ease. By  impregnating  the  gauze  which  is  held  in  place  by  the  metallic 
frame  of  the  mask^  with  some  medicinal  substances,  the  tuberculous 
prisoner  could  be  made  to  believe  that  the  instrument  was  worn  for 
his  own  personal  benefit  instead  of  for  the  benefit  and  protection  of 
others,  or,  as  they  might  think,  as  a  means  of  marking  them  as  indi- 
viduals suffering  from  a  contagious  disease.  Thus,  even  the  humane 
arguments  against  the  use  of  such  a  mask  woukl  have  no  foundation. 
Where  these  masks  have  been  used  bacilli  have  been  found  almost  con- 
stantly on  the  gauze.  Frankel's  and  Moszkowski's  experiments  have 
demonstrated  the  great  value  of  these  protective  masks,  which  can  easily 
be  disinfected.  The  gauze  should,  of  course,  be  changed  as  often  as 
necessary,  but  at  least  two  or  three  times  a  day,  and  immediately  be 
burned  after  removal. 

For  use  at  the  bedside  of  consumptive  prisoners,  Seabnry  &  John- 
son's well-known  square  pasteboard  cup  with  metallic  frame  or  Kny- 
Scheerer's  round  pasteboard  small  cuspidor  with  cover,  or  their  simple 
metal  spit  cup,  are  most  suitable.    When  filled  with  sputum  these  paste- 


470    PUBLIC  MEASURES  IN  THE   PROPHYLAXIS   OF  TUBERCULOSIS 

hoard  receptacles  and  tlieir  contents  arc  destroyed  1)}'  fire.  (See  Ap- 
pendix.) 

The  custom  of  whitewashing  a  room  in  wliich  ordinary  and  healthy 
individuals  stay  but  a  short  time  might  be  considered  a  hygienic  pro- 
cedure. When,  however,  this  process  has  been  adopted  for  the  sake  of 
doing  away  with  the  danger  of  tuberculosis,  its  efficiency  may  be 
doubted.  In  case  a  cell  has  been  previously  occupied  ])y  a  tuberculous 
prisoner,  he  has  surely  infected  its  walls,  if  not  directly  by  expecto- 
rating on  them,  he  has  done  so  by  droj)-infection.  Whitewasliing  is  well- 
nigh  useless,  since  dried  whitewash  is  aj)t  to  scale  off,  especially  when 
there  are  several  coats,  and  it  will  almost  constantly  produce  a  certain 
amount  of  dust  in  a  small  room  like  a  cell.  This  becomes  irritating 
to  a  sensitive  lung,  and  it  is  not  unlikely  that  it  may  be  an  aggravating 
factor  with  prisoners  who  enter  the  penal  institution  only  slightly  tuber- 
culous or  predisposed.  The  new  occupant,  if  at  all  debilitated,  physic- 
ally or  mentally  depressed,  is  strongly  exposed  to  contracting  tubercu- 
losis in  such  an  environment.  The  scales  of  the  new  coat  of  whitewash 
gradually  disintegrate  into  fine  dust,  unite  with  the  underlying  tubercu- 
lous dust,  and  make  an  infection  by  inhalation  par  excellence. 

The  method  of  inhaling  tuberculous  germs  from  infected  walls  has 
been  demonstrated  again  and  again,  not  only  inside  of  prisons,  but  in 
the  tenement  houses  of  the  poor,  and  even  in  the  apartments  of  the  rich 
(Flick,  '88).  Dr.  Eansom  expressed  himself  as  follows  in  regard  to  the 
delusion  that  whitewash  is  a  cleaning  and  disinfecting  agent : 

Observation  and  experiment  show  that  whitewash  really  promotes  the 
spread  of  tuberculous  disease.  The  fine  scales  and  floating  particles  that 
emanate  from  the  dried  whitewash  when  disturbed  not  only  irritate  the 
bronchial  mucous  membranes,  but  they  are  also  carriers  of  infection  to 
the  point  irritated. 

To  remedy  the  danger  arising  from  whitewashing  small  cells,  the 
writer  would  suggest  that  the  whitewash  be  replaced  by  oil  paint  which 
can  be  washed  oif  with  strong  disinfecting  fluids.  The  cells  should,  of 
course,  never  be  smaller  than  500  to  600  cul)ic  feet,  well  ventilated,  well 
lighted  by  natural  light  in  daytime  and  by  electric  light  at  night  (gas 
illumination  absorbing  too  much  oxygen).  In  the  Ohio  State  prison 
prisoners  with  sufficient  means  to  pay  for  having  their  walls  painted 
instead  of  whitewashed  can  avail  themselves  of  this  hygienic  safeguard. 
The  injustice  of  such  a  rule  is  evident.  On  the  writers  suggestion  the 
painting  of  all  the  cells  in  the  Columbus  prison  has  been  done  since. 

As  to  the  general  sanitation  of  prisons  as  far  as  it  relates  to  tuber- 
culosis, a  prison  with  all  its  annexes  should  be  constructed  so  that  there 
is  plenty  of  light  and  ventilation,  and  on  a  soil  that  is  dry  and  porous. 


TUBERCULOSIS   IX   PRISONS  AND   REFORMATORIES  471 

To  avoid  the  acquisition  of  a  predisposition  or  the  developing  of  an 
incipient  case,  all  prisoners  should  be  given  a  chance  to  exercise  several 
times  during  the  day  in  the  open  air,  even  if  it  is  only  for  a  short  time, 
and  during  that  time  they  must  not  only  be  permitted,  but  should  be 
enjoined,  to  take  deep  inhalations,  or,  better  yet,  regular  respiratory 
exercises.  The  exercise  in  the  open  air  should,  hovrever,  not  be  limited 
to  week  days.  According  to  the  prison  regulations  now  in  vogue  in 
most  penal  institutions,  prisoners  are  confined  to  their  cells  not  only 
from  the  hour  of  five  in  the  afternoon  to  six  in  the  morning,  but  also 
during  almost  the  entire  twenty-four  hours  of  Sundays  and  holidays,  and 
when  a  holiday  follows  a  Sunday,  or  vire  versa,  the  prisoners  are  necessa- 
rily locked  up  in  their  cells  for  two  successive  days.  That  such  close  long 
confinement  in  a  small,  ill-ventilated  cell  must  be  harmful  is  self-evident. 

In  well-conducted  prisons  the  inmates  are  required  to  bathe  regu- 
larly, and  their  skin  is  usually  in  good  condition.  To  the  prisoner 
predisposed  to  tuberculosis  or  one  whose  case  is  so  incipient  that  con- 
stant medical  supervision  is  not  necessary,  permission  for  daily  cold 
douches  should  be  given.  To  this  class  of  prisoners,  predisposed  or 
incipient,  it  seems  that  it  would  pay  the  State  to  give  food  containing 
a  little  more  of  the  nitrogenous  substances  and  the  carbohydrates  than 
the  regular  prison  fare  now  represents. 

One  predisposing  factor  to  tuberculosis  in  prisons,  which  seems  to 
have  been  overlooked  in  most  of  the  reports  on  the  .subject,  is  over- 
working the  prisoners.  AVhile  it  is  true  that  in  the  majority  of  prisons 
the  hours  of  work  are  rarely  more  than  those  of  the  average  free  labor- 
ers, we  must  not  forget  that  the  free  man,  laboring  eight  to  ten  hours 
a  day,  has  a  relatively  better  quality  of  food,  the  exhilarating  influence 
of  freedom  of  action,  and  naturally  superior  hygiene.  The  writer  does 
not  wish  to  make  this  statement  in  the  spirit  of  criticism,  but  simply 
to  point  out  the  general  likelihood  of  a  predisposed  individual  develop- 
ing tuljerculosis  more  rapidly  under  conditions  of  confinement  than 
when  in  normal  environments. 

The  writer  has  visited  a  number  of  prisons  where  the  workshops  were 
very  badly  ventilated,  overcrowded  with  workers,  often  overheated,  and 
where  there  should  have  lieen  dust  collectors  they  were  wanting.  For 
example,  tobacco  workers  under  the  best  conditions  are  prone  to  tuber- 
culosis. How  much  more  must  tliey  he  in  danger  in  a  prison  work- 
shop constantly  dust-laden,  where  there  is  hardly  elbow  room  and  the 
air  is  greatly  vitiated?  Since  it  is  a  very  common  practice  for  cigar- 
makers  to  paste  the  final  leaf  with  saliva,  it  must  be  evident  that  no 
prisoner,  even  slightly  afflicted  with  tul)erculosis,  should  be  permitted 
to  make  cigars,  leaving  aside  the  fact  that  such  conditions  are  sure  to 
aggravate  his  disease. 


472    PITBLIC  MEASURES  IN  THE  PROPHYLAXIS  OF  TUBERCULOSIS 

One  phase  of  the  subject  which  appertains  rather  to  the  welfare  of 
the  conmumity  at  large  is  the  pardoning  of  prisoners  far  advanced  in 
tuberculosis.  Whether  this  practice  of  restoring  the  pardoned  prisoners 
to  their  often  poor  families  is  always  a  wise  one  is  open  to  question. 
It  is  often  sad  enough  that  prisoners  who  have  contracted  tuberculosis 
in  prison,  or  whose  tuberculosis  has  been  aggravated  through  prison 
life,  should  be  discharged  at  the  expiration  of  their  sentence  without  any 
regard  to  where  they  will  go  or  what  they  will  do.  They  will  invari- 
ably constitute  a  source  of  infection  unless  they  have  been  prophylac- 
tically  trained  and  are  willing  to  continue  to  be  careful.  Prisoners 
virtually  dying  from  tuberculosis  should  not  be  pardoned  and  sent 
home  unless  the  authorities  are  sure  that  the  unfortunate  sufferer  will 
not  become  a  burden  to  his  family  nor  a  source  of  infection. 

As  to  the  value  of  agricultural  colonies  as  a  means  to  employ,  treat, 
and  cure  tuberculous  prisoners  in  the  earlier  stages  of  the  disease  there 
can  be  no  doubt.  In  connection  with  the  care  and  treatment  of  advanced 
tuberculous  prisoners  the  admirable  work  done  at  the  Texas  tuberculosis 
agricultural  colony  known  as  the  Wynne  State  Farm,  under  the  scientific 
and  humane  management  of  Dr.  Fowler,  should  be  mentioned.  The 
statistics  of  four  years  working  of  this  farm  are  as  follows : 

Total  number  discharged 34 

pardoned 30 

transferred 37 

died 46 

on  hand 33 

treated 180 

At  the  conclusion  of  Dr.  Fowler's  interesting  report  he  comments 
on  the  statistics  as  follows : 

I  will  say  that  the  37  men  transferred  are  virtually  cured,  and  at  least 
one  half  of  those  pardoned  and  discharged  were  in  good  physical  condi- 
tion, and  the  majority  on  hand  are  improving.  The  labor  of  the  180  men 
was  practically  of  no  value  anywhere  else  in  the  prison,  as  most  of  them 
had  reached  an  advanced  stage  of  tuberculosis  before  their  reception  at  the 
Wynne  Farm.  The  farm  is  more  than  self-sustaining,  if  the  expense  of 
guarding  the  prisoners  is  deducted.  The  men  all  occupy  the  same  build- 
ing, as  they  have  to  be  guarded  day  and  night. 

From  the  report  it  is  evident  that  tuberculosis  has  been  on  the 
decrease  in  that  prison,  and  there  is  no  doubt  that  the  tuberculous 
prisoner,  cured  through  the  healthful  and  invigorating  agricultural  pur- 
suit, will  be  returned  to  society  after  the  expiration  of  his  sentence 
many  times  a  better  member  of  it  than  he  was  formerly. 


TUBERCULOSIS   AND    DOMESTIC   ANIMALS  473 

Tuberculosis  and  Domestic  Animals. — Before  taking  up  the  subject 
of  combating  tuberculosis  in  domestic  animals,  and  thus  preventing  a 
possible  infection  of  human  beings,  it  is  but  right  that,  in  Justice  to  the 
still  existing  controversy  whether  tuberculosis  can  be  transmitted  from 
animal  to  man  and  from  man  to  animal,  we  give  the  conclusions  at 
which  the  majority  of  American,  British,  French,  and  German  scientists 
(the  Koch  school  excluded)  ^  have  arrived: 

1.  Bovine  tuberculosis  may  be  communicated  to  human  beings,  and 
in  such  cases  it  is  usually  children  that  are  aifected. 

2.  Tuberculosis  of  other  domesticated  mammals  (hogs,  sheep,  goats, 
etc.)  may  also  be  communicated  to  human  beings.  It  is  usually,  but  not 
always,  of  the  bovine  type. 

3.  The  tuberculosis  of  poultry  is  not  communicable  to  human  beings. 

4.  Parrots  and  some  other  varieties  of  cage  birds  may  be  affected 
with  a  type  of  tuberculosis  communicable  to  human  beings. 

5.  The  tuberculosis  of  human  beings,  as  a  rule,  is  not  communicable 
to  cattle,  but  is  communicable  to  pigs,  dogs,  and  cats.  The  bacilli  in 
a  certain  proportion  of  the  cases  of  human  tuberculosis,  however,  are 
virulent  for  cattle  and  produce  in  these  animals  a  fatal  generalized  tuber- 
culosis. 

6.  Precautions  should  be  taken  to  protect  human  beings  from  animal 
tuberculosis  by  a  careful  inspection  of  meat-producing  animals  at  the  time 
of  slaughter,  and  of  the  cows  from  which  milk,  cream,  and  butter  are 
produced   (Salmon).' 

In  a  book  destined  particularly  to  be  of  help  to  the  general  practi- 
tioner it  would  be  out  of  place  to  give  the  details  regarding  diagnosis, 
hygiene,  and  treatment  appertaining  to  tuberculosis  in  animals.  On 
the  other  hand,  it  would  seem  of  vital  importance  that  the  general  prac- 
titioner, and  particularly  the  one  residing  in  country  districts,  should 
be  familiar  with  the  latest,  best,  and  most  feasible  methods  of  i-epressing 
tuberculosis  in  domestic  animals,  for  he  certainly  Avill  be  called  on,  some 
time  or  another,  as  health  officer  of  his  community  or  as  an  adviser  to 
the  Board  of  Health,  for  help  and  suggestions. 

Some  very  concise  and  practical  suggestions  are  given  by  Dr. 
D.  E.  Salmon  in  the  report  which  appeared  in  the  Bidletin,  No.  38, 
of  the  Bureau  of  Animal   Industry,  the  careful  perusal   of  which  the 

■At  the  British  Tuberculosis  Congress,  in  1901,  Professor  Robert  Koch  delivered 
an  address  entitled  "  The  Combating  of  Tuberculosis  in  the  Light  of  the  Experience 
that  has  been  (iained  in  the  Successful  Combating  of  Other  Infectious  Diseases." 
In  this  atldress  he  said  that  experiments  hail  been  niade  by  himself  and  Professor 
Schiitz,  and  others  of  his  ])upils,  which  led  him  to  conclude  that  tuberculosis  was 
not  transmitted  from  the  lower  animals  to  man. — "  Twentieth  Century  Practice  of 
Medicine,"  vol.  xxi,  p.  781. 


474    PUBLIC  MEASURES  IN  THE   PROPHYLAXIS  OF   Tl^BERCULOSIS 

writer  strongly  rocoininends.  It  can  be  obtained  by  applying  to  the 
Bureau. 

Supervision  of  Slaughterhouses. — It  must  be  evident  that  no  effec- 
tual prevention  of  tuberculosis  contracted  through  infected  meat  is  pos- 
sible without  a  careful  inspection  of  all  animals  coming  to  the  slaughter- 
houses and  the  condemnation  of  all  diseased  ones.  This  feature  of  pre- 
vention is  by  no  means  perfected  as  yet,  and  will  not  be  imtil  there  are 
better  laws  (Federal,  State,  and  municipal)  and  a  better  cooperation 
between  the  respective  State  authorities.  This  latter  feature  is  par- 
ticularly important  to  prevent  the  clandestine  transportation  of  diseased 
cattle  from  one  State  with  good  bovine  laws,  which  are  strictly  enforced, 
to  another  State  with  either  less  good  laws  or  where  good  laws  are  not 
enforced. 

Protection  against  Infection  from  Tuberculous  Milk. — No  subject 
is  perhaps  more  important  to  the  general  practitioner,  particularly  to 
the  one  who  devotes  much  attention  to  diseases  of  children,  than  the 
subject  of  pure  milk.  That  the  procuring  of  clean,  pure  milk,  free 
from  pathogenic  germs,  is  a  very  essential  feature  in  the  combat  of 
tuberculosis  is  now  generally  understood.  The  battle  for  pure  milk  in 
New  York  City,  which  may  serve  for  an  example  to  other  cities,  dates 
back  to  1843,  when  Mr.  Eobert  H.  Hartley,  one  of  the  founders  of  the 
New  York  Association  for  Improving  the  Condition  of  the  Poor,  wrote 
what  was  then  said  to  be  the  only  volume  in  the  English  language 
devoted  to  the  scientific  treatment  of  milk  production.  In  1850  it  was 
published  in  more  popular  form,  entitled  "  The  Cow  and  Dairy,"  and 
was  a  potent  factor  in  the  "  swill-milk "  agitation  and  reform  that 
followed. 

It  is  due  to  this  association  that  a  milk  conference  was  recently 
called  and  a  committee,  composed  of  leading  sociologists,  philanthropists, 
and  physicians,  was  created.  The  committee  is  to  be  permanent  and 
is  to  work  in  cooperation  with  the  Board  of  Health  and  the  New  York 
County  Medical  Society,  and  all  those  engaged  in  or  related  to  the 
production,  handling,  and  distribution  of  milk.  From  the  first  report 
published  we  learn  that  the  New  Y^'ork  Association  for  Improving  the 
Condition  of  the  Poor  was  also  instrumental  in  having  the  law  of  18G4 
passed,  which  prohibited  the  adulteration  of  milk. 

Some  two  years  ago  a  movement  was  begun  to  secure  more  milk 
inspectors.  In  the  summer  of  1905,  at  Commissioner  Darlington's  re- 
quest, the  association  furnished  the  Health  Department  with  an  inspec- 
tor who,  from  April  1st  to  August  5th,  made  2,960  inspections,  exam- 
ined 3,770  specimens,  took  264  samples,  and  destroyed  6,739  quarts  of 
adulterated  milk.  Fifty-one  arrests  for  adulteration  resulted  in  the 
conviction  of  47  dealers  out  of  49  tried.     The  commissioner  also  trans- 


PROTECTION   AGAINST   INFECTION   FROM   TUBERCULOUS  MILK    475 

ferred  to  milk  iiis})eclion  150  sanitary  oflficers  from  other  fieldri  for  a 
time. 

In  190G  the  association  assisted  in  obtaining  an  appropriation  which 
enabled  the  Department  of  Health  to  double  its  staff  of  milk  inspectors 
and  cooperate  with  the  Evening  World  in  an  enthusiastic  campaign 
Avhich  led  to  a  marked  reduction  in  infant  mortality,  saving  several 
hundred  lives  between  July  and  September. 

The  following  are  the  most  important  conclusions  and  suggestions 
arrived  at  by  the  conference: 

Inspection  of  dairies  and  creameries  is  without  doubt  regarded  as  of 
the  first  importance. 

To  accomplish  this  with  reasonable  speed  and  thoroughness  sixty  to 
eighty  inspectors  in  the  country  are  needed.  The  milk  must  be  drawn 
from  healthy  cov/s  under  conditions  of  cleanliness  of  animals,  milkmen, 
premises,  water,  utensils,  and  milk  cans;  milk  must  be  immediately  cooled 
to  at  least  50°  F.,  and  so  delivered  at  creameries,  where  it  should  be 
handled  in  a  thoroughly  sanitary  manner,  and  further  cooled.  Inspection 
must  then  follow  it  every  step  of  the  way  to  the  consumer,  protecting  it 
from  contamination  and  never  permitting  its  temperature  to  rise  at  any 
stage  above  50°  F. 

The  expression  was  unanimous  that  nothing  can  render  such  inspec- 
tion unnecessary  or  reduce  its  importance. 

Equally  important  is  it  that  all  cans  and  bottles  shall  be  cleaned 
immediately  after  being  emptied,  and  so  sent  back  clean  to  the  country, 
where  they  should  be  sterilized  before  being  refilled.  Closely  allied  to 
this  is  the  necessity  for  improved  cans  which  can  be  cleaned  more  easily. 

The  improvement  of  conditions  in  retail  stores,  while  in  a  great  meas- 
ure covered  by  "  insi^ection,"  involves  much  besides,  such  as 

New  regulations  as  to  construction  and  handling  and 
conditions  in  stores,  all  tending  to  the  final  establishment  of 
model  milk  shops. 

Infants'  milk  depots  are  at  once  of  the  most  vital  importance,  being 
directly  related  to  infant  mortality,  and  within  the  possibility  of  early 
establishment. 

To  secure  the  cleanliness  of  the  vast  total  milk  supply  and  its  proper 
distribution  is  a  tremendous  task;  to  obtain  10,000  quarts  daily  of  clean 
milk  and  place  it  within  the  reach  of  the  people,  pasteurized  or  raw, 
modified,  in  feeding  bottles,  with  directions  from  physicians  and  nurses, 
as  indicated  in  the  report,  is  no  small  undertaking,  but  is  within  the 
power  of  more  than  one  single  philanthropist  in  this  city  to  render  pos- 
sible within  a  few  months. 

To  secure  anything  approaching  the  best  results  to  follow  such  inspec- 
tion, imi)rovement  in  shops,  and  establishment  of  infants'  milk  depots, 
the  education  of  the  people  must  go  forward. 


47G    PUBLIC   MEASURES  IN  THE   PROPHYLAXIS  OF  TUBERCULOSIS 

They  must  be  taught  the  value  of  milk  as  a  food  and  the 
absolute  need  of  cleanliness  in  handling  after  it  comes  into 
their  hands. 

Every  social,  educational,  and  philanthropic  agency  in 
this  city  should  lend  its  best  aid  to  intelligent  efforts  in  this 
direction. 

To  render  possible  the  accomplishment  of  these  ends,  regulations  and 
legislation  must  be  secured — city,  State,  and  Federal. 

A  constant  and  unceasing  pressure  along  all  these  lines,  backed  by  an 
enlightened  public  opinion,  is  necessary  to  permanent  reform. 

This  report  Avas  signed  by  Committee  on  Report :  Dr.  Rowland  G. 
Freeman,  as  Chairman ;  Mr.  John  E.  Sayles,  as  Secretary ;  Dr.  L.  Emmett 
Holt,  Dr.  Ernest  J.  Lederle,  Dr.  Linsly  R.  Williams,  as  members  of  the 
Committee  on  Report. 

What  philanthropy  in  cooperation  with  municipal  authorities  can 
do  may  best  be  seen  from  the  work  which  has  been  done  by  a  single 
philanthropist,  Mr.  Nathan  Straus,  during  the  last  fifteen  years.  There 
were  2,917,336  bottles  and  1,222,048  glasses  of  milk  sold  or  given  away 
this  season.  The  new  building  Mr.  Straus  is  erecting  at  a  cost  of  more 
than  $100,000  will  be  finished  and  equipped  with  a  large  pasteurization 
plant  this  winter,  so  as  to  be  in  full  operation  next  spring.  The  totals 
for  the  fifteen  years  show  the  dispensing  of  18,710,892  bottles  and  10,- 
089,674  glasses  of  this  milk.  Mr.  Straus's  plan  has  been  copied  in 
nearly  400  cities  in  all  parts  of  the  world. 

Dr.  Goler's  ('07)  opinion  on  the  regulation  of  the  milk  supply  of 
smaller  municipalities  than  that  of  New  York  is  particularly  instructive, 
and  in  view  of  the  excellent  results  obtained  in  Rochester  it  may  be  well 
worth  Avhile  to  give  his  conclusions  on  this  most  efficient  work: 

There  must  be  a  sufficient  number  of  inspectors,  really  to  inspect,  and 
through  such  inspections  to  determine  that  the  applicant  for  the  holder 
of  a  license  is  qualified  to  produce  and  distribute  milk.  To  such  a  one 
only  should  a  milk  license  be  issiied. 

1.  That  adequate  inspection  may  be  made,  a  sufficient  number  of  in- 
spectors must  be  employed  to  collect : 

a.  From  each  wagon  at  least  one  monthly  sample  for  bacteriological 
and  chemical  examination. 

h.  At  least  once  in  two  months  a  sample  from  each  store  offering 
milk  for  sale. 

c.  Every  city  dairy  and  every  store  to  be  scored  at  least  quarterly 
by  the  inspector  on  a  score  card  after  the  plan  of  those  used  by  the 
U.  S.  Department  of  Agriculture  and  the  Dairy  Department  at  Cornell 
University, 


HOUSING   OF  THE   MASSES,   GOOD  TENEMENT   HOUSE  LAWS     477 

2.  There  must  be  daily  inspection  of  the  iiu-ominpc  milk  at  each  rail- 
road station  for: 

a.     Condition  and  housing  of  cans  and  bottles  of  milk   in  shipment. 
h.     Conditions  of  empty  cans  reshipped. 

c.  Temperature  of  milk. 

d.  Inspection  of  railroad  samples  to  guard  the  retailers  against  fraud 
on  the  part  of  the  wholesalers. 

The  territory  from  which  the  city  draws  its  milk  supply  must  be 
mapped,  the  dairies  plotted,  the  roads  examined,  the  railroad  facilities 
noted,  and  routes  laid  so  that  every  farm  shipping  milk  to  the  city  may 
in  the  beginning  be  subjected  to  a  systematic  inspection  once  in  two 
months.  No  milk  must  be  permitted  to  enter  the  city  until  the  seal  of 
inspection  has  been  placed  on  it  by  the  inspector. 

When  for  one  reason  or  another  cow's  milk  of  absolute  purit}^  and 
free  from  tuberculosis  germs  cannot  be  obtained,  the  more  extensive 
use  of  goat's  milk,  which  seems  to  be  almost  always  free  from  tuber- 
culosis germs,  should  be  encouraged.  While  the  goat  ordinarily  is  looked 
on  as  a  rather  unclean  animal,  as  a  matter  of  fact  the  milch  goat  may 
be  tubbed  and  toweled  and  thus  easily  made  perfectly  clean.  For  chil- 
dren's feeding  such  cleansing  is  a  common  practice  in  certain  parts  of 
Europe. 

Housing  of  the  Masses,  Good  Tenement  House  Laws  and  their  Strict 
Enforcement  Essential. — An  important  feature  in  the  prevention  of 
tuberculosis  must,  of  course,  always  be  the  proper  sanitation  of  the 
home,  the  school,  the  workshop,  the  factory,  places  of  amusement  and 
recreation.  The  problem  of  housing  the  masses,  particularly  in  large 
cities,  is  too  vast  to  be  dealt  with  in  a  work  of  this  kind,  but  the 
fearful  prevalence  of  tuberculosis  in  many  of  the  tenement  house  dis- 
tricts of  our  large  cities  demands  attention.  New  York's  often-described 
"  lung  block "  on  Cherry  and  Market  Streets,  had,  ten  years  ago,  a 
death-rate  from  tuberculosis  of  37.5  per  cent,  w^hile  the  death-rate  in 
the  city  at  large  was  only  21.52  per  cent;  for  the  ten  years  from  189-1: 
to  190-1:  no  less  than  291  cases  of  tuberculosis  were  reported  to  the 
Board  of  Health  from  this  block,  and  since  the  new  tenement  house 
law  was  enacted  200  violations  have  been  filed  with  the  Tenement  House 
Department  against  these  unsanitary  dwellings.  Yet  in  spite  of  this 
condition,  in  spite  of  the  Tenement  House  Commissioner  and  the  men 
and  women  interested  in  the  antituberculosis  problem,  who  have  pleaded 
again  and  again  for  the  destruction  of  the  block  and  the  conversion  of 
it  into  a  park  or  playground,  the  lung  block  still  stands  because  of  the 
political  strength  of  its  owners.  Are  physicians  not  often  lacking  in 
civic  duty  by  not  interesting  themselves  more  in  public  and  political 
life? 


478    PUBLIC  MEASURES  IN  THE   PROPHYLAXIS  OF   TUBERCULOSIS 

Tlio  lesson  tliat  tlio  lung  Ijhx-k  loaches  is  simply  that  renovation 
does  not  pay  when  tiil)erculosis  in  any  house  or  hloek  has  heconie 
endemic.  There  are  numy  "lung  hlocks"  in  New  York  and  in  other 
large  cities  of  the  United  States.  Every  collection  of  dark,  foul,  un- 
ventilated  tenements  is  a  lung  hlock,  dealing  death  to  those  who,  hy  eco- 
nomic necessity,  not  from  choice,  must  live  there  and  call  these  disease- 
breeding  houses  by  the  name  of  home.  Such  conditions  should  make 
municipal  authorities  and  public-spirited  citizens  everywhere  realize  the 
need  of  better  tenement  houses,  where  the  laboring  population  may  have 
homes  with  light  and  air  in  plenty,  in  addition  to  modern  improve- 
ments, and  at  the  same  time  pay  no  more  rent  than  they  had  been 
obliged  to  pay  for  unsanitary  and  uncomfortable  quarters  in  old  and 
dilapidated  tenement  houses. 

All  the  general  practitioner  can  do  in  this  matter  is  as  a  citizen  to 
further  proper  tenement  house  laws  and  their  enforcement,  and  as  a 
physician  to  urge  his  wealthy  clients  to  help  in  the  building  of  as  many 
model  tenement  houses  as  possible.  Viewed  even  from  a  purely  utili- 
tarian standpoint,  it  might  be  stated  that  money  invested  in  model 
tenement  houses  gives  to  the  investor,  as  a  rule,  as  high  and  higher 
percentage  than  he  is  apt  to  receive  from  other  safe  investments. 

Those  desiring  information  regarding  proper  tenement  house  laws 
are  referred  to  the  admirable  reports  annually  issued  by  the  New  York 
Tenement  House  Department. 

Parks  and  Playgrounds. — Parks  and  playgrounds  have  appropriately 
been  called  the  "  lungs  "  of  a  city,  and  the  phthisiotherapeutist  knows 
only  too  well  what  this  phrase  signifies.  The  city  that  has  the  greatest 
number  of  large  and  small  parks  and  playgrounds  or  open-air  recrea- 
tion centers,  particularly  when  they  are  located  within  densely  crowded 
districts,  will  always  be  able  to  boast  of  the  lowest  mortality  rate  from 
tuberculosis  and  other  respiratory  diseases.  Here  again  is  a  chance  for 
the  physician  to  direct  into  a  useful  channel  the  practical  philanthropy 
of  a  wealthy  client  who  may  wish  to  do  something  for  his  fellow  men. 

In  speaking  of  the  importance  of  playgrounds  in  the  prevention  of 
tuberculosis,  one  cannot  do  better  than  to  quote  from  an  address  deliv- 
ered on  this  subject  by  Prof.  Henry  Baird  Favill,  President  of  the 
Chicago  Institute,  on  the  occasion  of  the  Playground  Conference  wdiich 
was  held  in  Chicago  last  year: 

It  is  not  at  all  sufficient  that  the  children  be  protected  during  their 
helpless  years  from  danger,  but  that  they  be  furnished  with  sturdy,  disease- 
resisting  bodies.  The  problem  of  tuberculosis  involves  a  deep  conviction 
as  to  the  principles  of  living  which,  even  though  it  can  be  inculcated  in 
their  youth,  would  be  as  rapidly  eradicated  by  their  contact  with  their 
elders,  unintelligent  and  fixed  in  habit,  except  their  knowledge  and  im- 


CREATION   OF   SCHOOLS   OF   FORESTRY  479 

pulse  can  be  kept  alive  by  special  advantages  and  inspirations.  .  .  .  Pro- 
tection of  tlie  child  must  be  the  watchword  under  which  this  refnrni  will 
be  achieved.  The  ideal  of  a  healthy  body,  the  obligation  to  protect  the 
child  in  its  siisceptible  years,  the  willingness  to  sacrifice  for  the  child  in 
material  ways  have  to  come  as  the  foundation  for  general  reorganization. 
The  scope  of  the  playground  movement  broadens  enormously  at  this 
point.  To  provide  generously  the  open  spaces  necessary  to  carry  on  the 
work  is  obviously  the  first  duty.  To  regard  this  work  when  done  as  an 
end  accomplished  is  scrupulously  to  be  avoided.  To  learn  to  regard  the 
playground  as  an  elementary  means  to  a  very  great  end  must  be  the  object 
of  our  propaganda. 

Public  baths,  also  baths  and  swimming  tanks  in  schools,  must  cer- 
tainly be  considered  an  important  factor  in  the  prevention  of  tuber- 
culosis, particularly  when  they  are  located  in  the  crowded  tenement 
house  districts  of  a  large  city. 

Emigration  from  City  to  Village. — Before  taking  up  the  subject  of 
the  sanitation  of  the  home,  as  far  as  its  internal  equipment  is  related 
to  the  prevention  of  tuberculosis,  it  is  necessary  to  speak  of  the  unfor- 
tunate tendency  toward  overpopulation  in  the  cities.  Physicians, 
statesmen,  and  philanthropists  who  are  interested  in  the  solution  of  the 
tuberculosis  problem,  besides  working  for  the  better  housing  of  the 
poor  and  the  creation  of  special  institutions  for  the  treatment  of  con- 
sumptives, have  an  additional  mission  to  perform.  The  tide  of  emi- 
gration from  village  to  city  should  be  reversed.  If  tuberculosis  has 
made  its  appearance  in  a  family  living  in  a  large  city,  the  physician 
should  exert  all  his  influence  to  induce  especially  the  younger  members 
to  migrate  to  the  country  and  seek  outdoor  occupations. 

Statesmen  should  protect  the  interests  of  the  farmer,  so  that  farm- 
ing will  have  more  attraction  to  the  rising  generation  than  it  has  had 
in  the  last  tw^o  decades.  Philanthropists  should  aid  the  statesmen  by 
endowing  institutions  for  instruction  in  scientific  and  profitable  agri- 
culture, and  also  by  providing  healthful  amusements,  good  libraries, 
and  other  educational  institutions  in  country  districts,  thus  making 
living  outside  of  large  cities  more  interesting  and  attractive  to  young 
people.  In  short,  the  love  of  nature  and  life  in  the  open  air  should  be 
more  cultivated.  In  the  proportion  in  which  this  is  done  tuberculosis 
will  decrease.  But  in  the  cities  also  open-air  life  should  be  more  encour- 
aged and,  after  the  example  of  many  Euro])ean  cities,  outdoor,  healthful 
amusement  places  should  be  established  for  the  masses.  The  recent  estab- 
lishment of  outdoor  theaters  in  some  of  our  American  cities  must  be 
highly  commended  by  all  those  interested  in  the  antituberculosis  crusade. 

Creation  of  Schools  of  Forestry  and  the  Preservation  of  Forests. — 
The  creation  of  schools  of  forestry  in  connection  witii  the  j)reservation 


480    PUBLIC  MEASURES  IN  THE  PROPHYLAXIS  OF  TUBERCULOSIS 

and  cull ivat ion  of  forests  in  many  States  where  a  wasteful  destruction 
of  trees  is  now  carried  on,  would  give  useful  and  healthful  employment 
to  a  numher  of  people,  as  well  as  render  the  region  inore  healthful. 
It  would  offer  attractive  careers  to  young  men  seeking  to  overcome  heredi- 
tary or  acquired  tendencies  to  tuhereulous  diseases.  There  is  no  doubt 
that  the  preservation  of  American  forests  against  wanton  destruction 
by  greedy  speciilators  and  by  the  too  frequent  fires  would  lead  to  an 
improvement  of  the  climatic  condition  of  many  regions  throughout 
the  country. 

The  question  what  to  do  with  a  patient  who  is  discharged  from  a 
sanatorium  as  a  cured  or  arrested  case  is  an  exceedingly  difficult  one. 
To  allow  him  to  resume  his  former  occupation  or  to  have  him  return 
to  the  unhygienic  home  environments  from  which  he  came  means,  in 
many  instances,  a  rela})se,  if  not  a  new  infection.  Everybody  agrees  that 
outdoor  work,  such  as  farming,  gardening,  surveying,  canvassing,  driv- 
ing carriages  or  wagons,  providing  not  too  much  lifting  of  heavy  weights 
is  connected  with  it,  would  provide  the  ideal  occupations.  For  women, 
suitable  outdoor  employment  is  harder  to  find.  There  is  great  danger 
when  too  much  strain  is  placed  on  the  system  of  the  former  invalid. 
Even  in  ease  of  the  most  complete  recovery  he  cannot  compete  Avith  a 
perfectly  healthy  man  or  woman. 

It  would  seem  that  the  most  feasible  way  to  prevent  the  danger  of 
a  relapse,  due  to  the  wrong  kind  of  occupation  or  to  a  possible  over- 
exertion from  too  heavy  work,  would  be  to  have  the  patient  live  and 
work,  for  at  least  one  year,  in  an  institution  which  might  be  called  an 
agricultural  or  horticultural  sanatorium  farm,  where  the  kind  and  the 
amount  of  work  which  the  recovered  patient  is  allowed  to  do  w^ould 
be  strictly  regulated  by  an  experienced  medical  supervisor. 

Experiments  in  this  direction  have  been  made  in  this  country  in 
the  Adirondacks,  and  an  interesting  article  on  the  subject,  under  the 
heading  of  "  The  Garden  of  the  Saranac  I^ake  Industrial  Settlement," 
appeared  in  Charities  and  the  Commons  of  December  7,  1007.  The 
idea  of  this  settlement  was  thought  out  by  students  of  the  sociologic 
problems  connected  with  tuberculosis.  It  was  established  as  an  experi- 
ment in  May,  1907.  During  six  months  of  its  existence,  thirty-one 
persons  have  had  either  temporary  or  continuous  employment ;  twenty 
of  these  workers  have  been  men,  eleven  women.  The  wages  paid  range 
from  fifteen  to  twenty  cents  an  hour.  The  former  occupations  of  the 
patients  were  those  of  laborer,  glassworker,  machinist,  butcher,  car- 
penter, clothing  cutter,  piano  tuner,  bookkeeper,  lithographer,  stenog- 
rapher, photographer,  typewriter,  bookbinder,  shoemaker,  carriage 
painter,  office  boy,  lady's  maid,  saleswoman,  dressmaker,  lawyer,  draughts- 
man,  and  teacher.     The  industries   thus   far   established   or   tried   are 


SANITATION   AT   HOME  481 

gardening,  jmultry-raising,  leather  work,  diet  kitchen,  sewing  and 
mending,  and  an  exchange  for  the  sale  of  articles  made  by  invalids  at 
their  homes.  Mrs.  William  E.  D.  Scott  is  the  superintendent.  The 
writer  of  the  article  above  referred  to  is  Curator  of  the  Department  of 
Ornithology  at  Princeton  University,  and  is  himself  an  enforced  resi- 
dent at  Saranac  Lake.  At  the  end  of  nine  months  he  had  so  far  recov- 
ered his  health  as  to  Ije  able  to  direct  actively  much  of  the  outdoor  work 
planned  by  the  organization  which  is  especially  devoted  at  present  to 
truck-gardening  and  poultry-raising. 

In  Pennsylvania  arrangements  are  being  made  by  the  Department 
of  Health  and  Charities  to  send  a  score  of  tuberculous  patients  from 
the  Philadelphia  General  Hospital  to  the  City  Tract  at  Byberry  farm. 
The  change  is  to  be  in  the  nature  of  an  experiment,  and  if  it  proves 
beneficial  a  greater  number  of  consumptive  patients  will  be  removed 
to  Byberry. 

Sanitation  at  Home. — The  sanitation  of  the  home  and  its  equipment 
to  prevent  tuberculosis  is,  of  course,  of  vital  interest  to  the  phthisiolo- 
gist.  The  model  tenement  home  should  give  to  its  tenants  light  rooms, 
good  ventilation,  perfect  plumbing,  proper  heating  facilities,  and  reason- 
able security  from  fire. 

To  make  the  air  in  homes  as  fresh,  pure,  and  sanitary  as  possible 
is  comparatively  easy  in  summer.  The  windows  and  doors  can  be  left 
open  so  as  to  make  the  air  inside  as  fresh  as  that  outside.  The  greatest 
difficulty  is  experienced  in  winter.  Yet  physicians  should  not  fail  to 
urge  those  in  their  care  to  renew  the  air  at  least  several  times  a  day 
b}'  opening  the  windows  and  doors  for  a  few  minutes.  Against  the 
fear  of  night  air — that  nightmare  of  our  ancestors — we  should  be  par- 
ticularly emphatic. 

When  there  is  a  tuberculous  invalid  in  the  famil}'  or  one  strongly 
predisposed  to  the  disease,  and  the  family  is  in  moderate  circumstances, 
or  for  some  other  reason  the  patient  must  be  treated  at  home,  the 
ingenuity  of  the  practitioner  will  be  taxed  to  the  utmost  by  his  desire 
to  install  the  sanatorium  treatment.  In  the  Appendix  (\'ll)  there 
will  be  seen  a  number  of  illustrations,  such  as  sleeping  shacks,  sleeping 
verandas,  etc.  The  poorer  the  people  the  more  difficult  is  the  problem. 
If  the  consumptive  sufferer  is  obliged  to  sleep  in  the  room  which  serves 
as  a  living  room  for  the  rest  of  the  family,  there  will  be  naturally  strong 
objections  in  winter  to  having  the  window  open  day  and  night.  It  is 
for  this  reason  that  I  devised  an  arrangement  which  I  call  a  window 
tent.  A  brief  description  may  help  the  general  practitioner  to  have  a 
window  tent  manufactured  if  the  device  cannot  be  procured  in  his  local- 
ity, or  if  some  one  in  the  family  has  ingenuity  and  mechanical  skill 
enough  to  make  one. 
32 


482    PUBLIC  MEASURES  IN  THE   PROPHYLAXIS  OF  TUBERCULOSIS 

Window  Tent  for  the  Open-air  Treatment  at  Home. — The  window 
tent  is  an  awning  which,  instead  of  being  placed  outside  of  the  window, 
is  attached  to  the  inside  of  the  room.  It  is  so  constructed  that  the  air 
from  the  room  cannot  enter  or  mix  with  the  air  in  the  tent.  The 
patient  lying  on  the  bed,  which  is  placed  parallel  with  the  window,  has 


Fig.  137. — Window  Tent  in  Use.     Note  celluloid  window.     (S.  A.  Knopf.) 

his  head  and  slioulders  resting  in  the  tent.  By  following  the  description 
closely  you  will  see  that  the  ventilation  is  as  nearly  perfect  as  can  be 
produced  with  so  cheap  a  device.  The  tent  is  placed  in  the  lower  half 
of  an  American  window,  but  it  does  not  quite  fill  the  lower  half  of 
the  frame;  a  space  of  about  three  inches  is  left  for  the  escape  of  the 
warm  air  in  the  room.  By  lowering  the  window  the  space  can  be  re- 
duced to  one  inch  or  less,  according  to  need.  On  extremely  cold  and 
windy  nights  there  need  not  be  left  any  open  space  at  all  above  the 
window  frame.  The  patient's  breath  will  rise  to  the  top  of  the  tent, 
the  form  of  which  aids  in  the  ventilation.  The  tent  is  constructed  of 
a  series  of  four  frames,  made  of  Bessemer  rod  suital)ly  formed  and  fur- 
nished with  hinged  terminals,  the  hinges  operating  on  a  stout  hinge 
pin  at  each  end  with  suitable  circular  washers  to  insure  independent 
and  easy  action  in  folding  the  same,  the  Bessemer  rod  being  hardened 
to  make  a  stiff  rigid  frame  to  insure  its  maintaining  the  original  form. 
The  frame  is  covered  with  extra-thick  yacht  sail  twill,  properly  fitted, 
and  having  elongated  ends  to  admit  of   their  beins  tucked  in  under 


WINDOW   TENT   FOR  THE   OPEN-AIR  TREATMENT   AT   HOME    483 

and  around  the  bedding  to  prevent  the  cold  air  from  entering  the  room. 
The  patient  enters  the  bed,  and  then  the  tent  is  lowered  over  him.  Or 
with  the  aid  of  a  cord  and  a  little  pulley  attached  to  the  upper  portion 
of  the  window,  he  can  manipulate  the  lowering  and  raising  of  the  tent 
himself.  Shutters  or  Venetian  blinds,  whether  they  are  attached  on  the 
inside  or  on  the  outside  of  the  window,  can  be  utilized  in  conjunction 
with  the  window  tent  as  a  screen  to  intercept  the  gaze  of  the  neigh- 
bors, and  in  stormy  weather  as  a  protection.  The  bed  can  be  placed 
by  the  window  to  suit  the  patient's  preference  for  sleeping  on  his  right 
or  left  side,  so  that  he  has  the  air  most  of  the  time  in  his  face. 

Another  advantage  of  the  window  tent  is  that  it  will  not  attract 
attention  from  the   outside.     The  bed   being  placed   alongside   of   the 


Fig.  138.— Window  Tknt  Raised,  Whi:n  Not  in  Use.     (S.  A.  Knopf.) 


window  will  be  convenient  for  the  majority  of  tlie  poor  who  have  small 
rooms.  If,  however,  the  bed  must  be  placed  at  a  right  angle  to  the 
window,  this  can  be  arranged  as  well.  A  piece  of  transparent  celluloid 
is  placed  in  the  middle  portion  of  the  tent  to  serve  as  an  observation 
window  for  the  nurse  or  members  of  the  family  to  watch  the  patient 
if  this  is  necessary.  It  also  serves  to  make  the  patient  feel  less  out- 
doors and  more  in  contact  with  his  family.  He  can,  if  he  desires,  see 
what  is  going  on  in  the  room.     If  the  window  tent  must  be  placed  at 


484    Pl^BLIC  MEASURES  IN  THE   PROPHYLAXIS  OF   TUBERCULOSIS 


a  right  angle  to  the  window,  the  o1jser\ation  glass  can  he  put  in  on  the 
side  (see  Figs.  137  to  140). 

It  goes  without  saying  that,  as  a  rule,  patients  should  not  smoke; 
when,  in  exceptional  cases,  this  can  be  allowed,  the  danger  of  the  cellu- 
loid window  becoming  ignited  must  be  impressed  upon  them  and  the 
greatest  caution  urged.  The  writer  prefers  celluloid  to  ordinary  glass 
for  tliis  jmrpose,  l)ecause  it  can  easily 
assume  tlie  vaulted  form  of  the  rest  of 
the  tent,  and  thus  even  the  slightest 
possiI)ility  of  an  air-pocket  formation 
is  avoided. 


T: 


f 


Srl  _v  J*= 


Fici.  I'.'M. — Window  Tknt.     \'ie\v  I'nua  out- 
side.    (8.  A.  Knopf.) 


Fig.  140. — Diagram  Showing  Ven- 
tilation OF  Window  Tent. 


If  it  is  necessary  to  raise  the  bed  to  tlie  height  of  the  window  sill, 
it  can  be  done  with  little  expense.  If  the  bed  is  of  iron  a  few  addi- 
tional inches  of  iron  piping  can  be  attached  to  the  legs  by  any  plumV)er 
or  one  handy  with  tools ;  raising  a  wooden  bed  can  be  accomplished  with 
equal  facility.  If  the  window  tent  is  to  serve  the  patient  only  during 
the  night,  the  tent  can  be  piilled  up  and  the  bed  moved  away  from 
the  window  during  the  day  and  the  window  closed.  Or  the  tent  can 
be  taken  from  the  hooks  and  put  out  of  the  way. 

The  window  tent  will,  of  course,  be  of  greatest  value  to  the  consump- 
tive sufferer  in  winter.  If  he  is  feverish,  or  his  stay  in  bed  is  advisable, 
he  can  spend  his  entire  time  in  the  window  tent.  If  the  people  are 
poor,  and  the  room  where  the  consumptive  sufferer  lies  serves  as  living 
room  for  the  other  members  of  the  family,  the  fact  that  the  well  mem- 


WINDOW  TENT   FOR  THE   OPEN-AIU  TREATMENT   AT   HOME    485 

bers  need  not  shiver  and  yet  the  patient  can  take  his  open-air  treatment, 
is  of  vital  importance  in  many  respects.  While  the  room  will  not  be 
quite  as  warm  as  if  the  window  was  entirely  closed,  it  will  be  much 
warmer  than  if  there  was  no  tent  in  front  of  the  open  window.  Laying 
aside  the  economic  advantages  to  a  poor  family  when  not  being  o])liged 
to  heat  more  than  one  room,  the  patient  feels  that  lie  does  not  deprive 
his  loved  ones  of  comfort  and  warmth,  and  that  lie  is  less  a  burden 
and  hindrance  to  their  happiness.  The  other  members  of  the  family, 
on  the  other  hand,  feel  that  they  can  give  the  patient  all  the  air  he 
needs,  and  that  he  himself  need  not  suffer  for  their  comfort. 

In  winter  the  patient's  jjed  must  be  covered  with  a  sufficient  number 
of  blankets  to  assure  his  absolute  comfort  and  warmth  throughout  the 
night.  Still,  this  covering  should  not  be  so  heavy  as  to  press  down  upon 
the  body  and  make  the  patient  feel  uncomfortable  or  tire  him.  The 
tightly  woven  blanket  is  a  better  protection  than  the  loosely  woven  one. 
To  the  poor  Avliose  disposal  of  blankets  is,  alas !  often  very  limited,  it 

may  be  valuable  advice  to  tell  them 
to  put  several  layers  of  newspapers 
between  the  coverings.  Outdoor 
Life  (December,  1905)  recommends 
to  have  a  dozen  layers  sewed  be- 
tAveen  two  layers  of  flannel.  This 
will  certainly  make  a  cheaj?,  light, 


Figs.  141  and  142.— Woolen  Hoods  for  Outdook  Sleeping. 

and  warm  covering.  In  extremely  cold  weatlier  the  patient,  while 
sleeping  in  the  window  tent,  should  wear  a  sweater  and  protect  his 
head  and  ears  with  a  wo(den  cap,  sliawl,  or  woolen  hchiiet  (see  Figs. 
141  and  14:3). 

Some  patients  will  complain  that  the  bright  light  awakens  them  too 
early  in  the  morning,  and   that  they  have  difTicuHy  in  going  to  sleep 


486    PUBLIC  MEASURES  IN  THE   PROPHYLAXIS  OF   TUBERCTtLOSIS 

again.  In  such  instances  I  counsel  the  patient  to  have  some  light 
weight  hut  dark-colored  material  (such  as  hlack  lisle  thread  hose)  to 
put  over  his  eyes.  This  usually  suthces  to  obviate  the  inconvenience 
caused  hy  the  bright  light. 

In  the  Appendix  (VII)  there  will  also  be  found  a  number  of 
devices  (tents,  half-tents,  reclining  chairs,  etc.)  to  facilitate  the  rest 
cure  outdoors  during  the  day  in  the  homes  of  the  poor.  When  there  is 
no  garden,  no  veranda,  no  roof,  which  can  be  utilized  for  outdoor  sleep- 
ing, the  window  tent  can  also  be  put  into  service  for  the  rest  cure  during 
the  day.  The  lied  is  moved  away  and  the  reclining  chair  is  put  in  its 
place.  The  latter  can  be  raised  to  the  necessary  height  by  wooden 
blocks  or  a  platform,  and  with  the  aid  of  blankets  and  comforters  the 
air  from  the  room  can  be  excluded,  and  the  patient  being  in  front  of 
the  open  window  breathes  only  outdoor  air. 

Dry  Air  and  the  Danger  from  Overheated  Dwellings. — Many  Ameri- 
can dwellings  and  public  buildings  are  heated  altogether  too  much.  A 
temperature  of  from  65°  F.  to  G8°  F.  should  be  sufficient,  especially 
when  care  is  taken  that  the  heat  produced  by  the  furnace  is  not  too 
dry.  The  excessively  dry  atmos2:)here  in  winter  in  many  public  buildings 
and  in  many  city  and  country  homes  often  gives  rise  to  nasal  catarrhs, 
a  condition  which  everybody,  but  especially  those  suffering  from  pulmo- 
nary diseases,  or  prone  to  them,  should  be  anxious  to  avoid.  Besides 
keeping  the  water  pan  in  the  furnace  constantly  filled,  there  should  be 
in  the  sitting  room  and  sleeping  rooms  humidifying  arrangements. 

The  humidifier  consists  of  a  wooden  or  metallic  box  placed  with  its 
open  side  over  or  before  the  register.  Layers  of  felt  are  suspended 
between  two  metallic  basins  containing  water;  the  upper  one  is  the 
smaller  and  is  placed  immediately  under  the  cover  of  the  humidifier, 
the  larger  one  below.  By  capillary  attraction  these  layers  of  felt  are 
kept  constantly  moist,  and  the  heated  air  coming  from  the  furnace 
passing  over  them  is  rendered  more  humid. 

More  simple  evaporating  devices,  however,  such  as  a  vessel  filled 
with  water  and  a  cloth  suspended  above  it  touching  the  water  so  as  to 
produce  capillary  attraction,  will  answer  the  purpose  of  rendering  the 
atmosphere  sufficiently  humid. 

Experience  has  proved  that  we  can  be  perfectly  comfortable  in  a 
temperature  of  65°  F.,  and  even  a  little  lower,  provided  that  the  relative 
percentage  of  moisture  is  sixty.  If  this  moisture  falls  to  thirty  or  to 
twenty  per  cent,  then  the  dry  throat,  dry  nose,  and  dry  skin  are  in 
evidence.  A  single  direct  reading  hygrometer  (Fig.  42),  while  not  over- 
accurate,  will  answer  for  all  practical  purposes. 

Danger  from  Dry  Sweeping. — Dust  must,  next  to  the  bacilli,  be  con- 
sidered the  greatest  enemy  to  the  tuberculous  invalid  or  to  the  indi- 


COMMON   HOUSE   FLY   AS  A   PROPACJATOR   OF   TUBERCULOSIS     487 

vidiial  predisposed  to  the  disease,  for  we  know  that  even  dust  free  from 
pathogenic  microorganisms,  when  inhaled  frequently  or  for  a  long  time, 
will  irritate  the  respirator}'  tract  and  make  it  more  susceptil)le  to  the 
invasion  of  the  tubercle  bacillus  and  other  microorganisms. 

There  is  pul)lishcd  an  excellent  little  leaflet  in  four  different  lan- 
guages which  the  Tul)erculosis  Committee  of  the  Charity  Organization 
Society  and  also  the  Health  Department  have  distributed  at  large.  It 
shows  how  the  danger  arising  from  dusting  and  sweeping  in  the  home 
may  be  reduced  to  a  minimum.  These  simple  and  comprehensive  rules 
were  suggested  to  our  committee  by  Prof.  T.  Mitchell  Prudden,  of 
Columbia  University. 

The  most  sanitary  and  ideal  method  of  cleaning  any  room  is,  of 
course,  the  vacuum-cleaning  method,  which,  it  is  to  be  hoped,  will  some 
day  be  cheap  enough  to  be  more  generally  available.  For  schools,  fac- 
tories, stores,  and  public  buildings  this  method  should  be  made  ol^li- 
gatory. 

To  sweep  unsprinkled  streets  and  raise  clouds  of  dust  should  be 
considered  a  municipal  crime.  No  sidewalks  or  streets  should  be  swept 
M'ithout  having  been  thoroughly  sprinkled.  Surface  street-car  com- 
panies should  be  compelled  to  sprinkle  their  tracks  at  regular  intervals 
in  hot  and  dusty  Aveather.  This  is  done  in  several  cities  by  cars  spe- 
cially devised  for  that  purpose.  Its  universal  adoption  is  an  urgent 
necessity. 

The  Common  House  Fly  as  a  Propagator  of  Tuberculosis. — An  im- 
portant factor  in  the  spread  of  tuberculosis  is  generally  omitted  in  all 
leaflets  on  the  subject — that  is,  the  common  house  fly.  It  would  seem 
that  an  item  showing  the  danger  of  this  insect  as  a  distributor  of  bacilli 
should  be  inserted.  The  abdominal  cavities  of  flies  caught  in  the  rooms 
of  consumptives  often  contain  the  living  tubercle  bacilli,  so  also  do  the 
fly  specks  scraped  from  the  walls  and  windows  in  rooms  where  con- 
sumptives live  and  particularly  where  their  sputum  receptacles  do  not 
have  any  covers.  The  danger  from  these  infected  insects  is  twofold. 
They  die  and  crumble  to  dust,  which  contains  the  bacilli,  and  the 
microorganisms  may  thus  enter  the  system  through  the  respiratory 
tract;  or  the  fly  may  infect  some  article  of  food  with  its  feet  or  excre- 
ment, whence  the  bacilli  contained  in  the  deposit  iind  their  way  into  the 
alimentary  tract  of  man  or  animal.  It  is  for  this  reason  that  we  should 
insist  that  all  sputum  receptacles  should  have  covers  and  never  be 
allowed  lo  remain  open. 

The  fly,  however,  may  not  only  be  a  distrilmtor  of  pathogenic  germs, 
])articularly  of  tubercle  bacilli,  but  it  is  inimical  by  its  very  presence  in 
the  sick  room.  By  its  interference  with  sleep  in  the  early  morning  hours 
it  unquestionably  exerts  a  lowering  etfect  on  the  vitality  of  the  tuber- 


488    PITBLIC   MEASURES  IN  THE   PROPHYLAXIS   OF  TUBERCULOSIS 

culous  invalid.  Thus,  to  any  of  the  circulars  on  the  prevention  of  tuber- 
culosis one  might  advantageously  add  a  paragraph  relative  to  the  de- 
struction of  the  house  fly,  or  it  may  be  even  better,  after  the  example 
of  the  New  York  Board  of  Health,  to  distribute  a  separate  circular  to 
that  effect.  1  copy  here  the  circular  relating  to  this  subject  recently 
issued  by  the  Health  Department : 

Keep  the  flies  away  from  the  sick,  especially  those  ill  with  contagious 
diseases.  Kill  every  fly  that  strays  into  the  sick  room.  His  body  is  cov- 
ered Avith  disease  germs. 

Do  not  allow  decaying  material  of  any  sort  to  accumulate  on  or  near 
your  premises. 

All  refuse  which  tends  in  any  way  to  fermentation,  such  as  bedding, 
straw,  paper  waste,  and  vegetable  matter,  should  be  disposed  of  or  cov- 
ered with  lime  or  kerosene  oil. 

Keep  all  receptacles  for  garbage  carefully  covered  and  the  cans 
cleaned  or  sprinkled  with  lime  or  oil. 

Keep  all  stable  manure  in  vault  or  pit  screened  or  sprinkled  with  lime 
or  kerosene  or  other  cheap  preparation. 

See  that  your  sewerage  system  is  in  good  order,  that  it  does  not  leak, 
and  is  up  to  date  and  not  exposed  to  flies. 

Pour  kerosene  into  the  drains. 

Cover  food  after  a  meal ;  burn  or  bury  table  refuse. 

Screen  all  food  exposed  for  sale. 

Screen  all  windows  and  doors,  especially  the  kitchen  and  dining  room. 

Burn  pyrethrum  powder  in  the  house  to  kill  the  flies. 

Don't  forget  that  if  you  see  flies  their  breeding  place  is  near-by  filth. 
It  may  be  behind  the  door,  under  the  table,  or  in  the  cuspidor.  If  there 
is  no  dirt  and  filth  there  will  be  no  flies. 

Prevention  of  Tuberculosis  in  the  School  Child. — In  the  prevention 
of  tuberculosis  school  hygiene  is  most  important.  The  writer  has  en- 
deavored to  point  out  the  great  responsibility  which  we  all  have,  par- 
ticularly the  medical  profession,  in  preventing  tuberculosis  among  the 
children  attending  the  public  schools.  If  the  child  has  an  hereditary  pre- 
disposition to  disease  l)ecause  one  or  both  of  his  parents  has  had  tuber- 
culosis or  syphilis,  been  afflicted  with  marked  nervous  or  mental  dis- 
order, or  addicted  to  alcoholism,  the  strain  of  school  life  not  infrequently 
suffices  to  bring  out  or  develop  the  hereditary  taint. 

If  the  home  environments  of  the  child  are  such  that  it  receives  either 
not  enough  or  insufficiently  nutritious  food,  does  not  get  enough  sleep 
or  must  sleep  in  an  ill-ventilated  room,  is  insufficiently  clad  and  his 
bodily  hygiene  generally  neglected,  or  if,  as  happens  too  often,  it  must 
contribute  by  its  "  child  labor  ''  toward  the  support  of  the  family,  we 
have  additional  predisposing  factors  to  tuberculosis. 


PREVENTION   OF   TUBERCULOSIS  IN  THE   SCHOOL   CHILD     489 

As  a  remedy  for  existing  conditions,  the  writer  suggests  that :  First, 
the  necessity  of  giving  the  child  more  years  to  play ;  second,  more  hours 
of  sleep  throughout  its  school  term  and  the  abolition  of  "  home  studies  " ; 
third,  the  training  of  teachers  in  the  diagnosis  of  diseases,  especially  in 
the  objective  symptoms  of  early  tuberculosis,  to  a  sufficient  extent  to 
facilitate  the  work  of  the  school  physician;  fourth,  small  enough  classes 
to  enable  the  teacher  to  come  in  close  contact  with  the  individual  pupil, 
and  classes  for  the  mentally  defective  and  backward;  fifth,  the  abolition 
of  child  labor,  not  only  in  factory,  workshop,  and  in  stores,  but  also  at 
home;  and  sixth,  the  arranging  of  the  curriculum  in  all  schools  so  that 
the  mental  development  is  not  pushed  to  the  detriment  of  the  physical 
welfare  of  tlie  child. 

Furthermore  to  be  suggested  is  the  teaching  of  rational  hygiene — 
physical,  mental,  and  moral — including  the  teaching  of  the  prevention 
of  tuberculosis,  venereal  diseases,  and  alcoholism,  to  school  children 
according  to  their  age  and  understanding,  by  the  regular  teacher  or 
special  teacher  or  the  school  physician. 

School  authorities  should  inaugurate  a  thorough  course  of  instruc- 
tion of  school  girls,  the  future  wives  and  mothers  of  the  nation,  com- 
prising sanitary  and  practical  housekeeping,  including,  of  course,  plain 
and  economic  cooking  and  the  art  of  serving  a  plain  meal  appetizingly. 

The  writer  also  advises  the  building,  equipment,  care,  and  cleaning 
of  the  schoolhouses  so  as  to  assure  the  best  possible  sanitary  conditions 
for  teachers  and  children  and  the  making  of  large  playgrounds  or  roof 
gardens  and  swimming  tanks  and  baths  as  indispensable  equipments  in 
every  school. 

Proper  breathing  exercises,  such,  for  example,  as  illustrated  in  Figs. 
143  to  146,  and  outdoor  singing,  recitation,  etc.,  when  weather  per- 
mits, should  prove  l)eneficiai,  and,  whenever  possible,  instruction  in  an 
adjacent  school  farm  or  school  gardens  might  form  a  part  of  the  cur- 
riculum. 

The  following  respiratory  exercises  have,  because  of  their  simplicity, 
been  found  most  efficacious  in  the  experience  of  the  author: 

In  front  of  the  open  window  or  out  of  doors  assume  the  position  of 
the  military  "  attention,"  heels  together,  body  erect,  and  hands  on  the 
sides.  With  the  mouth  closed  take  a  deep  inspiration  (that  is,  breathe  in 
all  the  air  possible  through  the  nose),  and  while  doing  so  raise  the  arms 
to  a  horizontal  position;  remain  thus,  holding  the  air  inhaled  from  three 
to  five  seconds,  and  while  exhaling  (breathing  out)  bring  the  arms  down 
to  the  original  position.  This  act  of  exhalation,  or  expiration,  should  be 
a  little  more  rapid  than  the  act  of  inspiration.  When  the  first  exercise 
is  thoroughly  mastered  and  has  been  practiced  for  several  days,  one  may 
begin  with  the  second  exercise,  which  is  like  the  first,  except  that  the 
33 


490    PITBLIC   MEASURES   IN   THE   PROPHYLAXIS   OF   TITBERCULOSIS 

upward  movement  of  the  arms  is  continued  until  the  hands  meet  over 
the  head. 

The  accompanying:  ilhistration  shows  the  positions  which  are  to  be 
taken  during  these  two  exercises.  Take  the  same  military  i)osition  of 
"  attention,"  and  then  stretch  the  arms  out  as  in  the  act  of  swinnning, 
the  backs  of  the  hands  touching  each  other.  During  the  inspiration  move 
the  arms  outward  until  they  finally  meet  behind  the  back.  Remain  in 
this  position  a  few  seconds,  retaining  the  air,  and  during  exhalation  bring 
the  arms  forward  again.  This  somewhat  difficidt  exercise  can  be  facili- 
tated and  be  made  more  eifective  by  rising  on  the  toes  during  the  act  of 
inhalation,  and  descending  during  the  act  of  expiration. 

When  out  of  doors  one  cainuit  always  take  these  exercises  with  the 
movement  of  the  arms  without  attracting  attention;  under  such  condi- 
tions   raise   the   shoulders,   making   a    rotary   backward   movement    during 


yKi 


Fig.  14.3. — First  and  Second  Breath- 
ing Exercise. 


Fig. 


144. — Third  Breathing 
Exercise. 


the  act  of  inhaling;  remain  in  this  position,  holding  the  breath  for  a  few 
seconds,  and  then  exhale  while  moving  the  shoulders  forward  and  down- 
ward, assuming  again  the  normal  position.  This  exercise  (Fig.  145)  can 
be  easily  taken  while  walking,  sitting,  or  riding  in  the  open  air. 

Young  girls   and   boys,   especially   those   who   are  predisposed   to    con- 
sumption, often  acquire  a  habit  of  stooping.     To  overcome  this  the  fol- 


PREVENTION   OF   TUBERCrLOSIS  IN  THE   SCHOOL   CHILD     491 

lowing  exercise  (Fig.  146)  is  to  be  recommended:  The  child  makes  his 
best  eflfort  to  stand  straight,  places  his  hands  on  his  hips  with  the  thumbs 
in  front,  and  then  bends  slowly  backward  as  far  as  he  can  during  the  act 


•::'^..;- 


5c  -;  J 


Fig.  145. — Breathing  Exercise  with 
Rolling  of  Shoulders. 


Fig.  146. — Exercise  for  Children  in 
THE  Habit  of  Stooping.  (Knopf 
prize  essay.) 


of  inhaling.  He  remains  in  this  position  for  a  few  seconds,  while  holding 
the  breath,  and  then  rises  again,  somewhat  more  rapidly,  during  the  act 
of  exhalation. 


Enough  school  physicians,  especially  trained  for  the  work  and  suf- 
ficiently remunerated,  should  be  attached  to  every  public  school  to  assure 
the  exclusion  of  cliildren  afflicted  with  contagious  and  communicable 
diseases,  or  otlicr  ])hysica]  defects,  including  bad  teeth,  with  a  view  of 
curing  or  correcting  the  disease  or  infirmity  tlii'ougli  either  private  or 
public  initiative. 

Tuberculous  teachers  sliould  not  be  employed  in  public  schools,  but 
if  they  have  contracted  tuberculosis  in  the  performance  of  duty,  it  is 
the  duty  of  the  municipality  to  provide  for  them  until  their  earning 
capacity  is  again  established. 

Tlie  establishment  of  municipal  seaside  or  country  school  sanatoria 


492    PUBLIC  MEASURES  IN  THE  PROPHYLAXIS  OF  TUBERCULOSIS 

for  tuberculous  children  wliore  some  of  tlie  tiil)erculous  teachers  might 
also  be  employed  profitably  is  an  urgent  necessity. 

It  would  also  be  wise  to  add  a  sufficient  number  of  trained  nurses 
as  school  nurses,  whose  duty  should  be:  first,  to  aid  the  school  physi- 
cian in  his  work ;  second,  to  visit  the  homes  of  the  physically,  morally, 
or  mentally  defective  children,  in  order  to  learn  if  home  conditions 
alone  are  not  responsible  for  the  defects  in  the  child.  The  writer  is 
convinced  that  hy  such  judicious  cooperation  of  teacher,  physician,  nurse, 
and  parents,  and,  if  the  case  demands  it,  by  the  help  of  an  organized 
charity  society,  many  of  the  underlying  causes  of  the  child's  troubles 
can  be  lastingly  remedied. 

Substantial  school  lunches  should  be  furnished  by  the  numicij^al- 
ity  at  a  nominal  ])rice  for  those  able  to  pay  and  gratuitously  for  the 
absolutely  poor. 

The  suppression  of  child  laljor  in  factories,  coal  mines,  mills,  work- 
shops, stores,  and  at  home  is  essential  if  we  wish  to  combat  a  predis- 
position to  tuberculosis  in  childbood.  The  child's  organism  when  en- 
feebled by  labor,  by  deprivation  of  sleep  and  outdoor  play,  is  sure  to 
become  an  easy  prey  to  the  tubercle  bacillus,  particularly  when  the  under- 
feeding and  unsanitary  housing  of  tlie  child  of  the  poor  is  added  to  its 
misfortunes.  There  is  an  equal  necessity  for  a  law  and  the  vigorous 
enforcement  of  it,  whereby  mothers  will  not  be  forced  to  work  until  the 
very  hour  of  their  confinement,  nor  be  obliged  to  resume  work  until  they 
have  regained  the  necessary  strength  to  do  so  after  their  delivery. 

Sanitation  of  Workshops,  Factories,  Stores,  etc. — The  sanitation  of 
factories,  workshoj)s,  department  stores,  and  other  establishments  where 
people  congregate  to  work,  should,  of  course,  be  made  a  matter  of  State 
and  municipal  regulation.  To  guard  against  direct  infection,  spitting, 
except  in  proper  receptacles  (elevated  S])ittoons,  Proedohl's  factory  cus- 
pidor, etc.,  see  Appendix  (VII),  should  ])e  prohibited,  and  any  repeated 
violation  of  the  antispitting  ordinance  punished  by  dismissal. 

The  public  telephone  in  such  places  and  elsewhere  also  may  serve  as 
a  means  of  the  propagation  of  tuberculosis.  An  arrangement  such  as 
pictured  in  the  Appendix  on  page  839  might  obviate  this  possible  dan- 
ger. The  thin  sheet  of  paper  over  the  transmitter  is  removed  after  each 
time  the  telephone  is  used,  and  the  discarded  papers  collected  and  burned 
every  evening. 

Antituberculosis  "Work  Among  Factory  Workers. — There  is,  how- 
ever, one  feature  of  antituberculosis  work  in  relation  to  this  that  can 
only  be  carried  out  by  the  physician  in  conjunction  with  the  employer 
or  owner  of  the  factory,  workshop,  or  store.  It  is  the  early  detection  and 
timely  and  proper  treatment  of  tuberculosis  among  employees.  To 
Franklin  T.  Fulton,  of  Providence,  K.  I.,  belongs  the  honor  of  being  the 


INSURANCE  AGAINST  TUBERCILOSIS  493 

pioneer  in  this  pliase  of  antituberculosis  work.  The  movement  was  in- 
augurated by  posting  on  the  bulletin  boards  of  the  shops  official  notices 
stating  that  the  management  of  the  mill  or  factory  had  provided,  with- 
out expense  to  the  employees,  a  physician  to  examine  anyone  who  had 
any  suspicion  that  he  might  have  tuljerculosis,  emphasizing  the  fact  that 
in  the  very  beginning  the  disease  can  be  cured. 

Two  establishments  which  took  the  matter  earnestly  employed  to- 
gether 5, '^00  men.  From  these  two  plants  Si  operatives  were  examined 
during  about  ten  months,  18  of  whom  were  found  to  liave  tuberculosis 
and  were  not  under  a  physician's  care.  Some  of  the  others  had  symp- 
toms suggesting  the  disease,  but  no  definite  signs  could  be  detected.  It 
was  found  that  most  of  these  men  were  living  in  a  very  unhygienic  way, 
and  their  symptoms  in  several  instances  quickly  disappeared  upon  their 
being  advised  liow  to  live.  Altogether,  the  work  in  connection  with  these 
two  establisliments  has  been  very  satisfactory,  and  wliile  tlie  number  of 
cases  treated  has  not  been  very  large.  Dr.  Fulton  doubted  if  there  are 
many  sanatoria  which  show  a  more  marked  improvement  in  as  large  a 
percentage  of  cases  and  in  so  sliort  a  time.  The  reason  for  this  he  cer- 
tainly does  not  believe  to  be  due  to  any  advantage  that  the  home  treat- 
ment has  over  the  sanatorium  treatment,  but  to  the  fact  that  the  cases 
are  detected  before  they  reach  an  advanced  stage. 

This  admiral)le  work  of  Dr.  Fulton  deserves  tlie  highest  praise,  and 
should  be  brought  to  the  attention  of  influential  and  philanthropic  em- 
ployers that  his  example  may  be  imitated. 

Insurance  against  Tuberculosis. — It  is  well  known  that  in  Germany, 
owing  to  tlie  compulsory  insurance  of  every  Avorkingman  and  woman 
against  accidents,  old  age,  and  disease,  including  tuberculosis,  the  anti- 
tuberculosis movement  has  made  strides  such  as  could  l)e  made  in  no 
other  country  witliout  that  provision.  These  insurance  companies  are 
so  prosperous,  and  they  have  fouiul  it  of  so  great  a  financial  advantage 
to  treat  their  tuberculous  policy  holders  at  the  right  time  and  at  the 
right  place,  tliat  they  have  built  themselves  a  number  of  tuberculosis 
sanatoria.  Some  of  these  are  among  the  best  equipped  of  the  land.  The 
Berlin  branch  of  the  "  Landesversicherung,"  for  e.\am})le,  established  at 
Belitz  one  of  the  finest  and  most  elaborate  institutions  of  its  kind, 
accommodating  no  less  than  300  tuberculous  patients. 

Aside  from  all  humanitarian  considerations,  it  would  seem  in  the 
interest  of  the  community  at  large,  the  welfare  and  well-being  of  the 
American  people  as  a  nation,  and  in  the  financial  interest  of  insurance 
companies,  policy  holders,  and  the  commonwealth,  iliat  tlie  time  had 
come  when  Americans  should  imitate  the  Gernuui  Invalidity,  Diseases, 
and  Old-Age  Insurance  Companies  under  State  supiprvision,  including, 
of  course,  under  insurance  against  disease,  all  tuberculous  affections. 


494    Pl'BLlC   MEASURES  IN   THE   PROPHYLAXIS  OF   TUBERCULOSIS 

To  combat  tuberculosis  as  a  disease  of  the  masses  successfully,  re- 
quires the  combined  action  of  a  wise  government  (Federal,  State,  and 
municipal),  well-trained  physicians  (trained  in  teaching  and  practicing 
prophylaxis  in  the  early  diagnosis  of  pulmonary  tuberculosis  and  mod- 
ern phthisiotherapy),  and  an  intelligent  people,  which  has  learned  the 
value  of  good  health  as  a  prime  factor  to  happiness  and  realizes  that 
the  mutual  insurance  against  accidents,  disease,  and  old  age  is  the  safest 
guard  against  the  possible  misfortunes  which  can  come  through  disease 
and  deformity. 

The  writer  closes  this  contribution  on  public  measures  in  the  pro- 
phylaxis of  tuberculosis  with  a  fervent  appeal  to  the  Government  to  take 
steps  which  will  place  federal  regulation  of  public  health  on  a  par  with 
that  of  the  leading  governments  of  Europe.  Germany  has  its  ministry 
for  medical  affairs,  with  a  cabinet  officer  at  the  head,  and  with  the  high- 
est medical  authorities  connected  with  the  Imperial  Office  of  Health 
("  Reichsgesundheitsamt ").  France  has  its  "  Conseil  superieur  de 
sante,"  equivalent  in  importance  and  power  to  the  Eeichsgesundheitsamt 
of  Germany.  Our  Eepublic  should  have  a  similar  office  to  guard  the 
health  of  the  nation. 

The  Committee  of  One  Hundred,  appointed  by  Section  One  of  the 
American  Association  for  the  Advancement  of  Science,  has  been  empow- 
ered to  work  for  Federal  regulation  of  public  health.  The  time  for  it 
seems  to  be  ripe,  and  what  the  creation  of  such  a  department  or  bureau 
of  health  ^  would  mean  for  the  welfare  of  the  people  of  this  country  in 
general,  and  particularly  regarding  the  combating  of  tuberculosis,  may 
best  be  realized  by  the  following  extract  from  an  address  delivered  by 
President  Eoosevelt  in  Provincetown : 

I  also  hope  that  there  will  be  legislation  increasing  the  power  of  the 
national  Government  to  deal  with  certain  matters  concerning  the  health 
of  our  people  everywhere;  the  Federal  authorities,  for  instance,  should 
join  with  all  the  State  authorities  in  warring  against  the  dreadful 
scourge  of  tuberculosis.  I  hope  to  see  the  national  Government  stand 
abreast  of  the  foremost  State  governments. 

» This  department  of  health  is  not  intended  to  encroach  on  the  fields  of  the 
State  boards  of  health.  The  thought  is  rather  to  arouse  the  State  health  boards  to 
redoubled  activity.  One  method  of  accompHshing  this  is  to  make  the  city  of 
Washington,  over  which  the  Federal  Government  has  full  power,  a  model  city  in 
hygiene  (Irving  Fisher,  "Federal  Organization  of  Health,"  Trans.  International 
Cong.  Tuberculosis,  Washington,  1908). 


ADDENDA  495 


ADDENDA 


Sumtnari/  of  Public  Measures  in  Propliylaxis  of  Tuberculosis,  Presented 
at  the  International  Congress  held  in  Washington,  D.  C. 

Economic  Meaning  of  Tuberculosis.— Some  interesting  new  calcula- 
tions have  been  jjre^ented  which  may  prove  helpful  in  stimulating  inter- 
est in  preventive  efforts  against  the  disease.  Y.  C.  Yaughan  figured  that 
from  200,000  to  250,000  inhabitants  of  this  country  die  annually  of 
tuberculosis.  Taking  only  the  lower  estimate,  it  may  be  calculated  that 
two  thirds  or  three  fourths  of  these  die  between  the  ages  of  eighteen 
«nd  forty-five — that  is  to  say,  at  a  time  of  life  when  the  earning  capacity 
is  greatest.  Estimating,  with  Darlington,  the  value  of  a  single  indi- 
vidual during  the  prime  of  his  life  at  only  $1,500,  and  taking  again  the 
lower  estimate  of  two  thirds  and  not  the  higher  estimate  of  three  fourths, 
the  economic  loss  which  accrues  to  the  United  States  through  the  un- 
timely death  of  these  100,000  jseople  is  no  less  than  $150,000,000 
annually. 

Another  calculation  of  the  cost  of  tuberculosis  in  the  United  States 
and  its  reduction  was  presented  by  Irving  Fisher.  He  estimates  the 
death-rate  from  tuberculosis  in  all  its  forms  in  the  United  States  at  164 
per  100,000  of  population  and  the  number  of  deaths  in  1906  as  138,000, 
and  he  concludes  that  at  this  rate,  of  those  now  living  in  the  United 
States,  5,000,000  people  will  die  of  tuberculosis.  The  average  age  at 
death  for  males  is  37.6  years ;  for  females,  33.4  years.  The  "  expecta- 
tion of  life  "  lost  (though  estimated  on  a  specially  high  mortality  rate) 
is  at  least  twenty-four  years,  of  which  at  least  seventeen  fall  in  the  work- 
ing period.  The  average  period  of  disability  preceding  death  from  tuber- 
culosis exceeds  three  years,  of  which  the  latter  half  is  a  period  of  total 
disability.  "  The  money  cost  of  tuberculosis,  including  capitalized  earn- 
ing power  lost  by  death,  exceeds  $8,000  per  death.  The  total  cost  in 
the  United  States  exceeds  $1,100,000,000  per  annum.  Of  this  cost  about 
two  fifths,  or  over  $440,000,000  per  annum,  falls  on  others  than  tlie  con- 
sum])tive.  An  effort  to  reduce  the  mortality  by  one  foiirth  would  be 
worth,  if  necessary,  an  investment  of  $5,500,000,000.  The  cost  of  treat- 
ing patients  at  sanatoria  is  repaid  many  times  over  in  lengthened  work- 
ing lives.  The  erection  of  isolation  hospitals  for  incurables  is  probably 
the  most  profitable  method  at  present  of  reducing  the  cost  of  tuber- 
culosis." 

Raising  of  Funds  for  Tuberculosis  Propaganda. — A  ])ra(ti(al  sugges- 
tion toward  this  end,  as  well  as  for  the  creation  of  general  interest  in 
tuberculosis,  is  contained  in  a  report  by  Miss  Clara.  E.  Dyar  of  a  scheme 
employed  in  Detroit.     By  this  it  was  possible  to  raise  in  a  single  day 


496    PUBLIC   MEASURES   IN   THE   PROPHYLAXIS   OF   TUBERCULOSIS 

$11^000  for  the  local  Societ}^  for  the  Prevention  and  Eelief  of  Tuber- 
culosis. Badges  representing  a  blue  star  on  pasteboard  were  sold 
throughout  the  city  for  ten  cents  each.  Great  eagerness  was  manifested 
by  people  of  all  ages  and  in  all  classes,  and  particularly  by  school  chil- 
dren, to  buy  and  wear  the  blue-star  badges  on  that  day.  Collection  sta- 
tions where  the  blue  star  was  for  sale  had  been  established  in  the  prin- 
cipal office  buildings,  shops,  hotels,  and  factories. 

Special  Dispensaries. — The  importance  of  tul)erculosis  dispensaries 
was  strongly  eni|)]iasized,  especially  by  Dr.  E.  W.  Philip,  of  Edinburgh, 
the  father  of  the  tuberculosis  dispensary  idea,  and  Professor  Calmette, 
the  pioneer  of  tuberculosis  dispensary  work  in  France.  Philip's  terse 
but  very  comprehensive  definition  of  such  a  dispensary  may  be  here 
quoted.  "  It  is  a  central  institution  devoted  to  the  guidance,  supervision, 
and  assistance  of  the  tuberculous  poor.  An  information  bureau.  A 
clearing  house.  A  center  for  the  supervision  of  home  treatment.  The 
connecting  link  or  knot  that  completes  the  chain  of  other  undertakings 
for  the  prevention  of  tuberculosis." 

For  Calmette  the  preventorium  or  supporting  dispensary  is  the  essen- 
tial instrument  of  social  preservation  against  tuberculosis.  It  does  not 
treat  patients  medically,  that  function  belonging  to  sanatoria,  hospitals, 
and  medical  polyclinics.  Its  mission  is  to  locate,  attract,  and  keep  under 
supervision  those  among  the  very  poor  who  are  peculiarly  exposed  to 
tuberculous  infection  and  those  who  are  already  affected.  It  selects 
patients  suitable  for  sanatorium  treatment ;  takes  charge  of  children  that 
are  menaced  or  already  attacked  by  the  disease,  promoting  their  proper 
treatment  and  cure  in  the  country  or  in  seaside  establishments.  Patients 
dangerous  to  their  surroundings  are  sent  to  isolation  hospitals.  Dwell- 
ings are  disinfected  and  contaminated  linen  sterilized  and  washed.  Spit 
cups  and  antiseptics  are  distrilmted. 

What  large  amount  of  work  can  be  done  by  tuberculosis  dispensaries 
with  judicious  management  was  well  brought  out  by  Alexander  M.  Wil- 
son in  his  report  of  the  work  of  the  Chicago  Tuberculosis  Institute, 
which  maintains  seven  special  dispensaries  in  various  districts  of  the 
city,  supplying  a  nurse  to  each  clinic,  and  through  its  central  office 
coordinating  the  work  of  the  dispensaries,  thus  preventing  duplication. 
In  less  than  seven  months  1,400  examinations  were  made. 

Compulsory  Examination  of  Children. — The  importance  of  this  was 
forcibly  presented  l)y  Baumel.  He  suggests  the  thorough  semiannual 
medical  examination  of  every  child  in  orphan  asylums,  kindergartens, 
nurseries,  and  schools.  He  furthermore  urges  that  uniform  reports  and 
certificates  be  transmitted  to  other  institutions  to  which  the  child  will 
go,  or  be  handed  to  the  child  at  the  end  of  the  school  year.  Finally, 
he  very  pertinently  points  out  the  necessity  of  having  the  tuberculous 


ADDENDA  497 

children  treated  in  institutions  wlicn  the  parents  cannot  have  them  prop- 
erly cared  for  at  home.  It  goes  witliout  saying  that  the  children's  teeth 
and  ears  should  be  included  and  attended  to  if  found  diseased,  a  point 
Avhich  was  also  insisted  upon  by  Woodbury.  Finding  that  ninety-six  per 
cent  of  school  children  have  decayed  teeth,  he  believes  that  instruction 
of  school  children  in  dental  hygiene  is  of  paramount  importance  in  the 
prevention  of  tuberculosis. 

Day  and  Night  Camps. — Although  these  camps  are  at  present  pri- 
marily intended  for  treatment,  reference  to  the  reports  presented  may 
be  made  here,  because  of  their  possible  adaptation  to  preventive  pur- 
poses. A  number  of  day  camps  are  now  in  operation  in  various  Ameri- 
can cities.  Especially  important  and  gratifying  is  the  work  of  the 
branches  of  the  Ked  Cross  Society,  through  whose  instrumentality  day 
camps  in  Washington,  Schenectady,  Albany,  and  Buffalo  have  been  estab- 
lished. The  Xew  York  branch  is  now  cooperating  with  the  authorities 
of  the  Medical  Department  of  the  Columbia  T^niversity  to  establish  a 
day  camp  on  the  roof  of  the  Yanderbilt  Clinic  in  the  city  of  Xew  York. 

W.  C.  White  presented  his  conception  of  a  night  camp.  He  suggests 
that  for  many  tuberculous  patients  the  night  camp  would  be  most  valu- 
able and  productive  of  a  great  deal  of  good  especially  for  those  needing 
supervision  or  for  those  who  cannot  get  proper  care  where  they  live. 
He  distinguislies  the  three  following  groups  of  patients,  for  many  of 
which  the  night  camp  he  believes  is  the  "  reasonable  and  most  valuable 
scheme  " :  I.  Those  still  working,  not  conscious  of  their  lesion,  with  (a) 
open,  (h)  closed  active,  and  (c)  healed  tuberculosis.  II.  Those  still 
working,  conscious  of  their  lesion,  who  from  their  existing  social  condi- 
tion are  compelled  to  work.  III.  Those  not  working,  conscious  of  their 
lesion,  yet  able  to  work  four  to  eight  hours  daily — (a)  old  sanatorium 
cases,   (h)  home-arrested  cases. 

Administrative  Control. — Biggs  reported  in  detail  on  tliis  subject, 
and  was  able  to  state  that  "  at  the  present  time  there  is  no  other  city 
in  the  world  in  which  the  health  authorities  have  so  thoroughly  organ- 
ized the  tiiberculosis  campaign  as  in  the  city  of  New  York."  E.  Koch's 
emphatic  indorsement  of  the  Xew  York  methods,  which  arc  in  detail 
desci'ibed  in  tlie  text,  deserves  mention. 

Naval  and  Military  Prophylaxis. — Kirsch  (German  navy)  ])ointed 
out  that  in  order  to  avoid  the  more  frequent  diseases  of  the  respiratory 
organs  in  the  navy,  due  to  climatic  changes,  the  cut  of  the  uniform 
sliould  be  modified  so  as  to  afford  better  ])rotection  to  the  throat  and 
chest.  He  suggests  also  that  the  men  whose  services  keep  them  below 
should  be  brought  on  deck  every  day  and  put  through  a  drill  of  gym- 
nastic exercises. 

Saar  (German  army)  suggests,  as  guiding  principles  in  the  preven- 


498     PUBLIC  MEASURES   IN   THE   PROPHYLAXIS  OF   TUBERCULOSIS 

tion  of  tuberculosis  in  tlie  German  army:  (1)  Refusal  of  recruits  sus- 
pected of  tuberculosis.  Positive  signs  of  tuberculosis  or  a  history  of  a  for- 
mer illness  of  a  suspected  tuberculous  nature,  or  an  inferior  physique 
(habitus  paralyticus,  thorax  pyriforniis,  floating  tenth  rib),  to  be  re- 
garded as  a  cause  for  rejection.  (2)  Eecruits  susjiected  of  tuberculosis 
having  been  enlisted,  should  be  carefully  examined  (X-ray,  subcutaneous 
and  conjunctival  tuberculin  tests),  and  if  found  tuberculous  should  be  at 
once  discharged.  (3)  Eecruits  who  steadily  lose  weight  should  be  care- 
fully examined  and  eventually  be  kept  under  observation  in  the  hospital. 
(I)  Tuberculous  soldiers  should  be  kept  in  hospitals  until  the  time  of 
their  discharge  from  the  army.  They  should  be  treated  in  special  tuber- 
culosis wards. 

He  recommends  also  for  the  systematic  prevention  of  dust  the  treat- 
ing of  the  floors  of  offices  and  barracks  with  a  dust-binding  oil  (dustless 
oil,  Westrumit).  Furthermore,  the  hardening  of  the  men  by  means  of 
regular  douching,  the  introduction  of  ''  naked  gymnastics  "  in  the  morn- 
ing after  rising,  the  establishment  of  light  and  sun  baths  in  the  open  air. 
Rather  radical  seems  his  recommendation  that  if  a  noncommissioned 
officer  desires  to  marry,  he  should  be  obliged  to  furnish  a  medical  cer- 
tificate of  his  prospective  bride,  and  also  that  those  serving  in  the 
canteen  must  prove  that  they  are  free  from  tuberculosis. 

Prison  Prophylaxis. — To  this  not  sufficiently  considered  problem 
J.  B.  Ransom  made  an  authoritative  contribution.  He  concluded  as  a 
result  of  his  observations  tliat  the  large  percentage  of  tuberculous  cases 
in  prisons  would  indicate  tuberculosis  to  be  more  or  less  closely  allied 
to  crime.  He  considers  the  tuberculous  prisoner  to  represent  one  of 
the  greatest  physical  menaces  to  the  general  social  order,  insisting  on  the 
necessity  for  a  law  making  mandatory  the  examination  of  every  pris- 
oner admitted  to  a  penal  institution.  The  experience  at  Clinton  prison 
illustrates  the  advantageous  results  obtainable  from  special  treatment  of 
the  tuberculous  incarcerated  criminal.  The  death-rate  from  tuberculosis 
during  the  past  fifteen  years  shows  a  decrease  of  seventy-one  per  cent  in 
the  prisons  of  New  York.  He  advocates  also  a  closer  study  of  the  disease 
in  prisons  where  most  satisfactory  opportunities  for  prolonged  experi- 
ment and  study  are  offered. 

Prostitution. — A  study  of  its  relation  to  tuberculosis  was  reported 
on  by  J.  Willougliby  Irwin.  An  examination  of  213  prostitutes  showed 
82  tuberculous — 63  in  the  first,  18  in  the  second,  and  1  in  the  third 
stage  (Turban).  He  believes  that  it  is  not  beyond  the  range  of  possi- 
l)ility  that  they  acquired,  or  at  least  some  of  them  acquired,  the  disease 
in  tlieir  intercourse  with  men  having  tuberculosis. 

Children's  School  Farms. — Children's  school  farms,  such  as  are  con- 
ducted in  New  York  under  the  admirable  directorship  of  Mrs.  Henry 


ADDENDA  499 

Parsons,  should  be  multiplied,  especially  in  large,  but  also  in  small, 
cities.  Such  farms,  when  located  in  congested  districts,  do  both  pre- 
ventive and  constructive  work.  Children  predisposed  to  tuberculosis  are 
given  an  opportunity  to  spend  the  greater  part  of  the  day  doing  garden- 
ing work,  learning  to  love  outdoor  life  and  outdoor  pursuits,  this  being 
cf  the  greatest  advantage  to  their  future  ph3'sical  welfare.  Mrs.  Par- 
son's report  made  on  this  subject  is  full  of  practical  suggestions.  She 
very  justly  says :  "  Such  gardens,  conveniently  located  throughout  the 
city,  would  accommodate  thousands  of  such  children  for  six  or  eight 
months  in  the  year,  year  after  year,  in  comparison  with  the  few  that  can 
be  sent  to  the  seashore,  mountain,  or  sanatoria  for  short  stays.  The  pos- 
sibility exists  of  teaching  hygiene  within  the  children's  comprehension,  by 
simple  experiments  with  plants  in  their  own  plots  which  will  lead  them 
to  see  why  fresh  air,  cleanliness,  and  sunshine  are  absolutely  necessary  to 
life  and  vigor  and  which  will  lead  them  to  demand  such  surroundings 
in  their  own  homes." 

Trained  Nurses. — The  social  significance  and  educational  possibilities 
of  the  nurses'  work  in  the  homes  of  the  poor  and  rich  was  dwelt  on  by 
Miss  Lillian  D.  Wald.  She  described  the  comprehensive  organization  of 
State  tuberculosis  work  in  Pennsylvania  under  State  Commissioner  Dr. 
Dixon,  with  nurses  and  adjuncts  in  county  centers  and  State  sanatoria; 
also  the  "  follow-up  "  work  of  hospital  and  dispensary  patients,  includ- 
ing instruction,  interpretation,  sending  to  suitable  hospital  and  dispen- 
sary, the  procuring  of  appropriate  employment,  etc.,  and  Avorking  for  the 
development  of  special  care  of  children  in  public  schools.  The  hospital 
training  schools  for  nurses  give  two  or  three  years'  education,  technically 
and  morally — an  excellent  preparation.  They  are  drilling  the  "  soldiers 
in  the  field,"  and  always  exercise  the  most  careful  selection  of  the  gradu- 
ates. The  social  significance  lies  in  the  ability  of  these  "  soldiers  "  to 
care  for  the  individual  victims  and  to  throw  light  upon  the  whole  sub- 
ject and  the  multiple  social  questions  involved. 

Public  Schools,  Colleges,  etc. — Luther  H.  Gulick  insisted  on  the  im- 
portance of  attacking  the  tuberculosis  problem  through  the  agency  of  the 
public  schools,  which  is  indicated  by  the  fact  that  ten  out  of  eleven  of 
all  the  children  of  the  United  States  come  under  the  jurisdiction  of  the 
public-school  system  for  approximately  seven  years — namely,  from  seven 
to  fourteen. 

G.  A.  Heron  gave  an  interesting  report  of  the  work  done  in  England. 
Special  instruction  in  elementary  hygiene  is  given  throughout  the 
United  Kingdom  to  prospective  teachers  in  the  training  colleges.  The 
course  of  training,  however,  is  so  adapted  as  to  avoid  even  the  semblance 
of  turning  out  teachers  who  might  imagine  themselves  to  be  specialists 
in  hygiene.    The  object  of  it  all  is  to  endeavor  to  secure  for  the  school 


500    PUBLIC  MEASURES  IN  THE   PROPHYLAXIS  OF   TUBERCULOSIS 

a  teacher  who  is  "  able  to  appreciate  the  conditions,  both  mental  and 
physical,  which  unfit  a  child  for  school  work,"  and  who  is  so  trained 
that  he  would  be  likely  to  find  children  who  failed  to  acquit  themselves 
creditably,  not  because  of  unwillingness  to  work,  but  because  of  some 
physical  defect  or  incapacity. 

William  Harmon  Norton  advocated  lectures  on  tuberculosis  in  col- 
leges and  university  extension  courses.  He  very  pertinently  pointed  out 
that  by  so  doing  hundreds  of  thousands  of  young  men  and  women  who 
go  out  from  college  to  become  citizens  of  exceptional  influence  in  their 
communities  are  enlisted  in  antituberculosis  work. 

Hygienic  instruction  in  schools  was  also  discussed  by  H.  B.  Jacobs, 
who  closed  his  interesting  communication  with  the  significant  words: 
"  Never  will  the  suppression  of  the  preventable  diseases  (including  tuber- 
culosis) be  secured  until  the  coming  generation,  rather  than  the  passing 
one,  is  instructed  in  the  proper  methods  to  be  pursued." 

Insurance  of  Workingmen  against  Sickness. — The  new  Hungarian 
law  relating  to  insurance  of  workingmen  is,  according  to  Johannes  Bar- 
tha's  communication,  doing,  and  is  destined  to  do,  even  greater  work  in 
the  prevention  of  tuberculosis  than  the  German  insurance  companies. 
The  municipal  regulations  adopted  against  tuberculosis  in  the  Freistadt 
Kolozovar,  East  Hungary,  has  accomplished  the  following  objects  with 
the  aid  of  the  insurance  companies:  The  recent  revision  of  the  building 
regulations  improving  the  living  conditions  of  the  masses,  the  early  clos- 
ing of  saloons,  antispitting  regulations,  the  prohibition  to  shake  out  dust 
cloths  on  the  street.  Furthermore,  provisions  must  be  brought  to  market 
in  absolutely  clean  vessels,  baskets,  etc.  Fruits,  pastry,  etc.,  must  be 
protected  from  flies;  confectioner}^  may  be  exposed  for  sale  only  in  cases 
covered  with  tightly  fitting  glass  lids,  and  customers  are  not  permitted 
to  finger  the  wares  for  the  pur})ose  of  making  a  selection.  Wise  abattoir 
regulations.  Eooms  occupied  by  persons  who  died  of  tuberculosis,  their 
bedding,  and  the  clothing  used  by  them  are  disinfected  by  the  city. 

Resolutions. — The  following  resolutions  were  adopted  by  the  Con- 
gress, and  they  reflect  the  new  prominence  given  to  the  social  aspects  of 
the  tuberculosis  problem,  of  which  the  establishment  for  the  first  time 
of  a  section  devoted  entirely  to  those  aspects  was  a  most  gratifying  mani- 
festation.    It  was  resolved : 

1.  That  the  attention  of  State  and  central  governments  be  called 
to  the  importance  of  proper  laws  for  the  obligatory  notification,  by  medi- 
cal attendants,  to  tlie  proper  health  authorities,  of  all  cases  of  tubercu- 
losis coming  to  their  notice,  and  for  the  registration  of  such  cases,  in 
order  to  enable  the  health  authorities  to  put  in  operation  adequate  meas- 
ures for  the  prevention  of  the  disease. 

2.  That  the  utmost  efiEorts  should  be  continued  in  the  struggle  against 


ADDENDA  501 

tu])erculosis  to  prevent  the  conveyance  from  man  to  man  of  tuberculous 
infection  as  the  most  important  source  of  the  disease. 

3.  That  preventive  measures  be  continued  against  ])ovine  tubercu- 
losis, and  that  the  })ossibi]ity  of  the  propagation  of  this  to  man  be 
recognized. 

4.  That  we  urge  upon  the  public  and  upon  all  governments  (a)  the 
establishment  of  hospitals  for  the  treatment  of  advanced  cases  of  tuber- 
culosis, (h)  the  establishment  of  sanatoria  for  curable  cases  of  tuber- 
culosis, (r)  tlie  establishment  of  dispensaries,  day  camps,  and  night 
camps  for  aml)ulant  cases  of  tuberculosis  which  cannot  enter  hospitals  or 
sanatoria. 

5.  That  this  Congress  indorses  such  well-considered  legislation  for 
the  regulation  of  factories  and  workshops,  the  abolition  of  premature 
and  injurious  labor  of  women  and  children,  and  the  securing  of  sanitary 
dwellings,  as  will  increase  the  resisting  power  of  the  community  to 
tuberculosis  and  other  diseases. 

6.  That  this  Congress  indorses  and  recommends  the  establishment  of 
playgrounds  as  an  important  means  of  preventing  tuberculosis  through 
their  influence  upon  health  and  resistance  to  disease. 

7.  That  instruction  in  personal  and  school  hygiene  should  be  given 
in  all  schools  for  the  professional  training  of  teachers. 

8.  That  whenever  possible,  such  instruction  in  elementary  hygiene 
should  be  intrusted  to  properly  qualified  medical  instructors. 

9.  That  colleges  and  universities  should  be  urged  to  establish  courses 
in  hygiene  and  sanitation,  and  also  to  include  these  subjects  among  their 
entrance  requirements,  in  order  to  stimulate  useful  elementary  instruc- 
tion in  the  lower  schools. 


PAET   Y 
TREATMENT 


IXTRODUCTION 
By  EDWARD  L.  TRUDEAU 

No  generally  accepted  treatment  of  ])ulnionary  tubej^culopis,  beyond 
the  climatic  cure,  can  be  said  to  have  existed  before  Brehmer,  in  1859, 
demonstrated  by  his  sanatorium  methods  the  great  value  of  regulation 
of  the  details  of  the  patient's  daily  life,  and  instituted  the  now  generally 
accepted  and  universally  practiced  open-air  method,  in  which  fresh  air, 
rest,  and  careful  alimentation,  with  or  withoiit  specially  favorable  cli- 
matic conditions,  are  the  main  factors  utilized.  For  the  first  fifteen 
3^ears  Brehmer's  teachings  made  but  little  impression,  but  during  the 
following  twenty  years  the  open-air  treatment,  whether  in  or  outside 
of  a  sanatorium,  whether  under  favorable  or  unfavorable  climatic  con- 
ditions, has  been  generally  accepted  and  gradually  adopted  all  over  the 
world  as  giving  the  best  results  in  the  management  of  all  forms  of 
tuberculosis. 

At  present,  life  in  the  open  air  and  generous  alimentation  are  uni- 
versally recommended,  but  the  great  value  of  absolute  rest  while  symp- 
toms of  activity  are  present,  and  relative  rest  at  all  times,  as  tending 
to  limit  autotoxemia,  and  the  imperative  need  of  the  regulation  of  the 
daily  life  for  many  months  at  a  time,  can  as  yet  hardly  be  said  to  be 
generally  appreciated,  except  by  specialists  and  sanatorium  physicians. 
The  exact  value  of  climate  is  still  a  disputed  subject,  but  it  is  difficult 
to  understand  why  climate  should  l)e  disregarded  entirely  while  all  other 
factors  which  go  to  make  up  a  favorable  environment  for  the  patient  are 
insisted  on.  No  doubt  good  results  could  be  and  are  obtained  witliout 
any  specially  favorable  climatic  influences,  but  it  seems  hardly  rational 
to  insist  on  tlie  value  of  the  minutest  details  of  the  patient's  surround- 
ings and  habits  of  life,  and  deny  absolutely  any  influence  of  climate 
as  a  factor  in  securing  the  most  favorable  environment  obtainable  for 
the  patient. 

The  modern  and  now  generally  accepted  treatment  of  tuberculosis  by 
the  open-air  method  aims  simply  at  bringing  tlie  patient's  general  health 
to  tlie  highest  possil)le  standard,  thus  develoj)ing  the  natural  defensive 
resources  of  the  iiidividiuil.  and  rendering  the  soil  as  unfavorable  as 
possible  for  the  growth  and  sjjivad  of  the  tubercle  bacillus  through  the 
system.     Successful  as  this  treatment  is  in  nuiny  cases,  especially  where 

505 


506  TREATMENT 

the  disease  is  detected  in  its  incipieney  or  is  not  of  too  acute  a  type,  it 
naturally  has  its  limitations,  and  from  a  condition  of  absolute  hopeless- 
ness and  pessimism  as  to  the  cure  of  tuberculosis,  the  public  and  the 
profession  are  now  in  danger  of  forgetting  the  persistence  and  relapsing 
nature  of  tuberculosis,  of  exaggerating  what  can  be  accomplished  by  a 
few  months  of  favorable  environment,  of  underestimating  the  limita- 
tions of  the  open-air  method,  and  especially  the  time  required  to  obtain 
permanent  results. 

The  arrest  or  cure  of  pulmonary  tuberculosis  by  the  sanatorium  and 
open-air  method  requires  time,  and  produces  too  often  but  a  relative 
cure,  which  in  a  great  many  cases  is  maintained  only  if  the  patient 
can  return  to  a  mode  of  life  and  surroundings  which  make  but  little 
demand  on  his  resisting  powers.  That  a  patient  whose  disease  has  been 
arrested  in  a  sanatorium  is  not  fitted  to  return  at  once  to  the  trying 
conditions  of  life  which  the  modern  struggle  for  existence  so  often  ren- 
ders necessary,  is  gradually  becoming  apparent. 

What  is  true  in  the  treatment  of  pulmonary  tuberculosis  is  equally 
true  in  the  treatment  of  all  other  tuberculous  manifestations  in  the  body. 
The  so-called  surgical  forms  of  tuberculosis,  where  the  disease  attacks 
the  bones,  joints,  or  skin,  are  best  treated  by  the  hygienic,  dietetic,  open- 
air  method,  in  or  outside  of  sanatoria,  with  or  without  special  climatic 
advantages,  but  with  the  addition  of  conservative  surgical  measures. 

If  the  good  results  obtainable  by  the  sanatorium  and  open-air  method 
could  be  made  permanent — that  is,  if  a  certain  degree  of  immunity  to 
relapse  could  be  obtained  by  any  method — the  work  of  such  institutions 
would  be  much  more  encouraging.  The  future  outlook  for  progress  in 
the  treatment  of  this  disease,  as  for  all  other  chronic  bacterial  infections, 
would  seem  to  be  in  the  discovery  of  some  specific  method  of  limiting  the 
ravages  of  the  bacteria  in  the  living  organism,  and  the  light  which  ex- 
perimental medicine  during  the  past  twenty  years  has  been  shedding 
on  the  mechanism  of  infectious  diseases,  would  indicate  that  success 
is  most  likely  to  be  attained  by  the  discovery  of  some  safe  method  of 
producing  artificial  immunity  by  the  inoculation  of  bacterial  vaccines. 

It  has  taken  many  years  of  tireless  experimentation  to  demonstrate 
the  possibility  of  producing  any  appreciable  degi'ee  of  artificial  immu- 
nity to  tuberculosis  in  animals.  ^Yith  this  advance  the  names  of  Koch 
and  Behring  in  Germany,  McFadyean,  Wright,  and  Douglass  in  Eng- 
land, de  Schweinitz,  Trudeau,  Pearson,  and  Gilliland  in  this  country, 
are  closely  connected.  Koch's  discovery  of  tuberculin,  and  his  appli- 
cation of  this  suljstance  to  the  treatment  of  tuberculosis,  mark  an  era  in 
the  specific  treatment  of  this  disease.  The  failures  and  disasters  which 
followed  his  announcement  and  brought  tuberculin  into  such  disrepute, 
were  evidently  due  in  a  great  measure  to  our  ignorance  of  the  principles 


INTRODICTION  507 

of  artificial  immunization,  to  faulty  methods,  and  to  a  lack  of  appre- 
ciation of  the  extreme  toxicity  of  this  most  powerful  agent. 

Of  late,  with  improved  methods  of  application,  with  a  better  appre- 
ciation of  the  potency  and  action  of  tuberculosis  toxins,  some  clinicians 
are  reporting  more  encouraging  results  in  the  therapeutic  use  of  the 
various  tuberculins.  The  work  of  Wright  and  Douglass  on  the  opsonins, 
and  the  relation  of  the  opsonic  index  to  artificial  immunization  by  tuber- 
culosis vaccine,  and  Professor  von  Behring's  extensive  laljors  on  the  pro- 
duction of  artificial  immunity  in  cattle,  indicate  that  the  future  of  the 
specific  treatment  of  ti;borculosis  in  man  by  some  immunizing  method 
is  full  of  promise.  The  prevention  of  tuberculosis  can  be  advanced  by 
nothing  so  sureh^  and  rapidly  as  by  a  successful  specific  method  of  curing 
the  disease.  When  science  shall  have  given  us  such  a  method,  the  control 
of  tuberculosis,  with  all  it  means  to  mankind,  will  be  near  at  hand. 


CHAPTER  I 

SPECIFIC    TREATMENT 
By  LAWRASON  BROWN 

HISTORICAL    INTRODUCTION 

The  discovery  of  the  tubercle  bacillus  was  quickly  followed  by  many 
attempts  to  destroy  it  in  the  tissues  of  tlie  infected  organism  by  the 
administration  of  various  substances  found  to  kill  it  in  vitro.  The 
literature  of  this  period  abounds  in  reports  of  attempts  of  this  kind,  and 
many  substances  were  recommended  which,  if  used  in  sufficient  strength, 
would  have  killed  the  host  as  quickly  as  the  parasite.  These  so-called 
"  false  specifics  "  will  be  discussed  elsewhere. 

The  study  of  the  pathology  of  the  disease  showed  that  it  was  impos- 
sible in  any  case  to  attack  the  germ  in  the  midst  of  caseous  matter  or  in 
old  tuberculous  foci  where  there  were  no  or  very  few  blood-vessels.  This, 
however,  is  no  argument  against  the  use  of  any  substance  that  can  be 
borne  by  the  blood  in  such  strength  that  it  will  kill  or  weaken  the 
tubercle  bacillus  and  not  injure  the  tissues,  for  the  tubercle  bacilli  in 
old  tulierculous  foci  are  of  no  danger  to  the  body  unless  they  escape  into 
the  blood  or  lymph  stream,  where  such  substances  could  speedily  attack 
them.  While  such  a  body  has  not  been  and  is  not  likely  to  be  found, 
the  whole  svibject  of  artificial  or  acquired  immunity  rests  anatomically 
on  this  basis. 

However  this  may  be,  chemistry  has  long  been  called  on  to  furnish 
new  agents  for  use  in  the  treatment  of  tuberculosis,  and  it  must  be 
acknowledged  that  it  has  been  overworked.  Since  the  discovery  of  the 
tubercle  bacillus  we  have  had  a  means  of  testing  the  germicides  experi- 
mentally, and  none  has  proved  of  any  value  in  treatment. 

The  excellent  results  obtained  by  the  hygienic-dietetic  treatment  of 
tuberculosis  is  now  acknowledged  by  all,  but  few  realize  that  its  discov- 
erer (Brehmer)  attributed  for  a  long  time  its  beneficial  influence  to 
some  specific  property  connected  with  certain  climates,  or  "  immune 
zones."  The  idea  of  "  specific  climates  "  has  long  since  given  place  in 
discussion  to  the  question  of  the  value  of  *'  climate,"  but  the  "  specific  " 
value  of  high  altitudes  is  still  recognized  by  the  use  of  the  pneumatic 
508 


HISTORICAL   INTRODUCTION  509 

cabinet,  and  more  recently  by  tbe  advocacy  of  balloon  ascensions.  There 
is  little  to  uphold  these  views. 

Eobert  Koch,  in  IHUO  (*90,  A  and  B;  '91,  A  and  B),  announced  that 
he  had  discovered  in  tuberculin  a  cure  for  tuberculosis.  Having  noted 
that  tuberculous  and  healthy  animals  react  very  differently  to  a  subcu- 
taneous injection  of  living  virulent  tubercle  bacilli,  he  was  led  to  the  dis- 
covery of  tuberculin.  Tlie  first  form  he  experimented  with  was  a  non- 
concentrated  broth  filtrate  from  a  culture  of  human  tubercle  bacillus, 
now  known  as  bouillon  filtre  (Denys).  Koch  considered  tliis  a  weak 
tuberculin,  and  discarded  it  for  the  stronger,  original  tuberculin  (0.  T.). 
He  advised  the  use  of  the  original  tuberculin  only  in  early  cases,  with 
a  first  dose  of  1  nigm.,  which  should  be  repeated  until  there  was  no 
longer  any  reaction.  Then  2  mgm.  should  be  given  in  the  same  way,  and 
so  on.  He  believed  it  so  acted  on  the  circulation  of  the  parts  about  the 
foci  that  the  diseased  tissue  died  and  softened,  or  was  discharged  in  toto. 
A  failure  of  reaction  was,  therefore,  due  to  the  destruction  and  lack  of 
tuberculous  tissue,  and  so  healing  he  believed  was  accomplished.  The 
avoidance  of  reactions  was  not  mentioned.  This  view  has  long  since 
been  given  iip  by  Koch. 

Notwithstanding  these  cautions,  tuberculin  was  administered  to  all 
sorts  of  cases,  and  many  a  poor,  far-advanced  consumptive  was  hurried 
to  his  grave.  A  patient,  for  instance,  was  given  tuberculin  and  reacted  to 
104°  F.  on  the  following  day,  when  he  received  a  second  dose  with  sim- 
ilar results.  This  was  continued  in  some  cases  until  death  ensued.  A 
few  observers  protested  (Guttman  and  Ehrlich,  '91)  against  this  over- 
dosing, but  were  unheeded,  and  finally  a  storm  of  indignation  arose 
which  reached  its  climax  when  Yirchow  ('91)  stated  that  he  found  sof- 
tening and  recent  extension  of  disease  in  patients  treated  with  tuber- 
culin and  dying  of  tuberculosis,  and  the  period  of  "  tuberculin  delirium  " 
was  over. 

It  is  manifestly  unfair  to  select  pathologic  changes  occurring  in  a 
patient  dying  of  tuberculosis  either  as  proof  for  or  against  any  line  of 
treatment  unless  these  changes  are  such  as  rarely,  if  ever,  occur  in  un- 
treated cases.  Yirchow  later  acknowledged  that  all  the  changes  he  had 
observed  do  occur  in  untreated  patients  dying  of  tuberculosis.  The  only 
accurate  pathologic  data  as  to  the  value  of  tuberculin  would  be  those 
obtained  from  patients  treated  with  tuberculin  and  dying  of  an  acute 
intercurrent  disease,  as  Bandelier  and  Roepke  point  out. 

The  age  of  "tuberculin  terror"  may  be  said  to  have  begun  at  this 
time,  and  he  who  used  tuberculin  was  looked  on  by  many  as  a  criminal. 
A  few  men  (Trudeau,  Goetsch,  Klebs,  Petruschky,  von  Euck)  continued 
the  use  of  tuberculin,  and  to  them  is  due  the  fact  that  the  period  of 
"tuberculin  renaissance,"  which  began  a  few  years  ago,  came  to  pass. 


510  SPECIFIC  TREATMENT 

Much  cliemieal  work  Avas  done  on  0.  T.  by  many  men,  who  tried  to 
separate  a  beneficial  snl)stance  from  tliose  ca{)al)le  oi'  injuring  tlie  patient. 
Hunter  ('91)  carefully  analyzed  tnl)ei-culin,  and  obtained  by  precipita- 
tion with  ammonium  sulphate  a  substance  (Modification  B)  which  he 
thought  superior  to  0.  T.  Trudeau  used  the  same  j^rocedure  with  the 
broth  filtrate,  but  neither  of  these  were  found  of  more  value  than  0.  T. 
Klebs,  who  was  one  of  the  first  to  work  along  this  line,  has  consistently 
adhered  to  his  belief  that  by  treating  the  0.  T.  with  bismuth  iodid,  and 
filtering  off  the  precipitate,  he  was  able  to  obtain  the  beneficial  sul)stancc 
by  further  precipitation  by  alcohol  (tuberculocidin).  This  has  not  been 
widely  used,  but  some  report  good  results  from  its  oral  administration. 

Koch  early  recognized  tliat  0.  T.  produced  no  perfect  inmiunity  to 
tuberculosis,  and  he  also  tried  to  separate  from  the  tubercle  bacilli  the 
beneficial  agent  which  he  believed  it  contained,  for  the  whole  tubercle 
bacillus  when  injected  subcutaneously  produced  abscesses.  By  extraction 
with  sodium  hydrate  he  obtained  tuherculin  nU-aJinum  (T.  A.),  which 
on  account  of  its  abscess-producing  qualities  he  quickly  discarded.  Hav- 
ing observed  that  at  death  many  tissues  failed  to  contain  tubercle  bacilli 
where  they  had  apparently  been  present,  he  sought  some  means  whereby 
he  could  make  the  tubercle  bacilli  more  absorbable,  for,  he  argued,  had 
this  but  occurred  earlier  in  the  animals,  immunity  might  have  been  ac- 
quired. The  results  were  unsatisfactory,  and  he  finally  announced  a  new 
tuberculin — tuberculin  residuum  (T.  R.)  (Koch,  '97) — consisting  of  an 
emulsion  of  pulverized,  water  extracted,  virulent  tubercle  bacilli.  The 
water  extract  he  called  tuherculin  ohere  (T.  0.),  and  said  it  contained 
the  fever-producing  substances  and  should  not  be  used.  This  new  tuber- 
culin, he  believed,  should  be  used  so  as  to  avoid  all  strong  reactions,  but 
the  results  were  not  satisfactory. 

Finally,  in  1901,  Koch  ('01)  recommended  for  use  an  emulsion  of 
tubercle  bacilli  wliich  he  said  should  be  given  in  increasing  doses  in 
spite  of  reactions,  first  subcutaneously  and  finally,  if  necessary,  intra- 
venously, having  in  view  the  production  of  a  strong  agglutinating  power 
in  the  serum.  This  was  the  beginning  of  the  "  tuberculin  renaissance," 
and  since  this  time  many  tuberculins  have  been  widely  used. 

The  work  of  Goetsch,  published  in  1901  wifh  a  postscript  by  Koch, 
paved  the  way  in  Germany  for  a  wide  use  of  tul)erculin,  while  in 
America  Trudeau's  ('07)  work  has  had  the  same  influence. 

Denys's  work  ('07)  called  attention  to  the  filtered  bouillon  culture 
of  tubercle  bacilli  (B.  F.)  and  emphasized  emphatically  the  great  care 
necessary  in  tlie  use  of  any  tuberculin.  Trudeau's  recent  papers  have 
also  laid  great  stress  on  this  point.  Like  strychnin,  arsenic,  and  many 
other  drugs,  tuberculin  may  be  of  value  when  given  properly,  and  is 
certainly  a  most  potent  poison  when  injudiciously  given. 


SCHEMA  FOR  TUBERCl'LINS  AND  TUBERCLE  BACILLUS  VACCLNES    51 1 

From  his  oracular  communications  von  Behring  would  lead  us  to 
supj)ose  that  lie  had  solved  the  proltleni  of  making  at  one  and  tlie  same 
time  the  tul)ercle  hacilli  Ixith  ahs^orhahle  and  unal)le  to  produce  tu- 
herculosis  when  injected  into  man  or  animal.  Proof  of  this  is  still 
lacking. 

Vaughan  (and  Wheeler,  '07)  has,  with  his  split  products  of  the 
tuhercle  hacillns,  endeavored  to  separate  the  poisonous  from  the  hene- 
ficial  part,  and  he  uses  the  latter  for  immunization.  It  acts,  he  lielieves, 
hy  promoting  bacteriolysis. 

More  recently  still  Deycke  and  Eeschad  Bey  ('07)  have  obtained 
from  a  streptothrix  found  in  lesions  of  leprosy  a  waxy  substance  which 
they  have  named  nastin.  Apparently  it  has  a  Itacteriolytic  action  on  the 
tubercle  bacillus  Avhen  injected  subcutaneously,  and  can  only  be  used, 
the}'  believe,  in  very  early  stages,  on  account  of  the  toxemia  that  would 
otherwise  occur. 

Livierato,  Klebs,  and  Maragliano  all  claim  to  have  obtained  some 
bacteriolytic  action. 

The  work  of  Moeller,  Loewenstein,  and  TJappoport  from  Belzig,  of 
Turl)an,  Schnoeller,  and  Frey  of  Davos,  of  Wright  of  England,  of  Mara- 
gliano of  Italy,  of  von  Beln-ing  of  Marlmrg,  and  of  many  others  too 
numerous  to  mention,  has  done  much  to  throw  light  on  this  most  sug- 
gestive and  intricate  subject. 

SCHEMA  FOR  TUBERCULINS  AND  TUBERCLE  BACILLUS 

VACCINES 

The  following  scliema  of  tuljerculins  and  tul)ercle  bacillus  vaccines  is 
arranged  in  three  large  groups,  according  as  use  is  made  of  the  culture 
fluid,  the  tubercle  bacillus  or  both  culture  fluid  and  tubercle  bacillus. 
The  culture  fluid  of  the  first  group  consists  of  Koch's  original  formula, 
and  the  various  preparations  are  grouped  according  to  the  strain  of 
tubercle  bacilli  and  the  amount  of  heat  employed.  Tlie  preparations  of 
the  tubercle  bacillus  are  discussed  in  a  similar  manner,  but  are  grouped 
under  four  heads — dead  l)acilli,  living  bacilli,  extracts  of  bacilli,  and 
decomposition  products.  In  the  third  large  group  of  "  Culture  Fluid 
and  Extract  of  Tubercle  Bacilli,"  other  formulas  of  bouillon  have  been 
used,  which  is  taken  into  consideration  as  well  as  the  strain  of  tubercle 
bacillus  and  the  degree  of  heat. 

I.    FILTRATE    OF    CTLTri^E    (TvOCTT'S    FOI^MFLA) 

Filtration  through  paper  or  candles  (Berkefcld.  ('Ii;iiiiberland, 
etc.). 


512  SPECIFIC  TREATMENT 

A.  Human  Types 
a.  Unhealed  h.  Heated 

1.  Unchanged  B.  F.  (Koch,  Dcnys,  to  60°  (".  or  less 

Trudeau).  1.  To    30°    on    water    hath    after 

2.  Precipitated    (^114)280^    Mod.  filtration    through     porcelain 

B.  (Trudeau).  (Maragliano). 

3.  Filtered  and  evaporated  to  one     2.   Filtration,  then  concentration  to 

tenth  in  vacuum  (or  thermo-  one  tenth  at  57°  (Ai'loingand 

stat  at  37°  C.)  TOA  (Speng-  Oninai'd). 

ler's  toxoid.  h.  Heated 

to  100°  C. 

1.  Fractional  distillation  under  N. 

(hacillosine,  Vaillant). 

2.  Sterilized,  filtered,  diluted  with 

1\S)  and  glycerin,  10  gms. 
toxine,  Lannoise. 

B.  Bovine  Types 

IJnheated  and  heated    ( tlieoretical). 

C.  Avian  Types 

1.  Unlieated:  Unchanged — A.  "  B.  F."  (theoretical)   Courmont  and 
Dar.  experimental. 

2.  Heated  (theoretical). 

D.  Piscine  types  (theoretical) 

E.  Other  "  cold-blooded  "  types   (theoretical) 

F.  Acid-fast  types  (theoretical) 

II.    BA("ILLA1?Y    BODIES 

A.  Human  types  (dead) 

a.   Untreated  h.  Treated 

1.  Allowed  to  (lie  (.lousset).  1.  By  grinding  without  heat,  cen- 

trifuged  and  glycerin-treated: 
T.    E.     (some    extraction    with 

water). 
B.  E.  (hacillary  emulsion). 

2.  By  lieating  to  60°  C.  (Wright). 

3.  Extraction  with  ether.    Fat-free 

bacilli  (treated  with  iodin 
and  KI  given  internally 
(Cantacuzene) ). 


SCHEMA  FOR  TUBERCULINS  AND  TUBERCLE  BACILLUS  VACCINES    513 
B.  Other  strains  (dead) 

C.  Human  types   (living) 

a.  Unchanged  h.  Attenuated  hy 

Bovo-vaccine  (v.  Behring).  1.  Decomposition. 

Tauruman  (Koch-Schiitz).  2.  Heat. 

3.  Prolonged  growth. 

4.  Chemical      means      (unsuitable 

media). 

5.  Glycerin  (Levy). 

6.  Passing  through  refractory  ani- 

mals— blindworm     ( Moeller ) , 
turtle   (Friedmann). 

D.  Avian  types  (living) 
Hericourt  and  Eichet,  McFad3'ean. 

E.  Bovine  types  (living) 
Spengler,  Klemperer  (in  man). 

F.  Cold-blooded  types  (living) 

Blindworm   (Moeller),  turtle  (Friedmann),  frog  (Knester). 

EXTRACTIOXS    OF    BACILLARY    BODIES 

{Only  human  types  used) 

a.   Unheated  h.  Heated 

1.  By  alkalies  T.  A.  (Koch).  1.  Water  and   concentrated    (100° 

2.  By  water  T.  O.   (Koch).  C.)  (Maragliano). 

Watery  extract  (von  Huck).  2.  Glycerin  and  water   (150°   C). 

3.  B}^   pressure:    tubeivulo-phismin  T.  D.  R.  (v.  Behring). 

(Biiclmer  and  Halm).  3.  Fractional  distillation  at  differ- 

4.  By  cliloral  hydrate,  etc.  ent  temperatures. 
Tubcrkidose       )                                       Tuberculol   (Landmann). 
Tulase                 v  (v.   Behring). 

Tulaselaktin      ) 

5.  By  cldorofonii   and  ether    (Au- 

clair). 

6.  By  oil    (Siallero). 

7.  By  pure  H,.S()„  etc   (Tuherku- 

lotoroidin,  Ishigami). 
34 


514  SPECIFIC  TREATMENT 

DECOMPOSITION   PRODUCTS    OF    BACILLARY   BODIES 

1.  Tuberculinic  (nucleic)  acid  (Ruppel,  Levene). 

2.  Tuberculosin  (Ivuppel). 

3.  Tuberciilosamin  (Euppel). 

4.  Nucleoproteid  (3,  Levene). 

5.  Split  products  (Yaughan). 

6.  Alkaloid  of  tubercle  bacilli,  crystalline  toxin  treated  witb  Ca  per- 
manganate— tuberculinum  (Baudron).  (Not  from  T.  B.  Nastin 
(Deycke-Eeschad  Bey). 

III.    CULTURE    FLUID    PLUS    BACILLARY    BODIES 
A.  Bouillon — Koch's  Formula 

I.  Human 
a.  Unheated  (theoretical), 

h.  Heated  to  100°  C. 

a^.  Old  (original  tuberculin  (tubercle  bacilli  water  bath  at  100° 
C.)  boiled  in  bouillon  and  evaporated  to  ten  per  cent  orig- 
inal volume — Koch). 

1.  Precipitated  by: 

a-.  Alcohol  (sixty  per  cent) — purified  (Koch). 

b^.  (NHJ^SO,,  Hunter's  Mod.  B. 

c^.  By    alcohol,   chloroform,    benzol,    tuberculinum    de- 

paratum  (Klebs)   (discarded). 
d-.  Sodium-bismuth-iodid   in  acetic   acid   and   then  by 

alcohol.    Antiphthisin  (Klebs)  discarded. 
e-.  Alcohol  and  sodium-bismuth-iodid.     Tuberculocidin 

(T.  C,  Klebs). 

2.  Extracted  with  NaOH  (Weyl). 

3.  Oxidized  by  HgO, — oxytuberculin  (Hirschf elder). 

h'^.  Tubercle  bacilli  of  standard  virulence  used,  bouillon  evaporated 
to  eight  per  cent,  filtered  and  sterilized.  Jacobs  ('04) 
tuberculin   (T.  J.). 

c\  Heated  to  60°   C.  or  less   (theoretical). 

II.  Bovine 

a.  Unheated — theoretical. 

6.  Heated— P.  T.  0.  (Perlsucht  tuberculin)    (Spengler). 

III.  Avian 

a.  Unheated — theoretical. 

b.  Heated  and  evaporated  (avian  "old  tuberculin")    (Roux). 


VARIETIES  OF  TUBERCULIN   USED   CLINICALLY  515 

IV.  Piscine 
a.  Unheated — theoreticaL 

6.  Heated  and  evaporated  (piscine  old  tuberculin)  (Terre,  Ramont  and 
Eavaut,  Bataillon,  Moeller  and  Terre). 

V.  Other  Cold-blooded  Tubercle  Bacilli 

a.  Unheated — theoretical. 

h.  Heated  and  evaporated.  Blindworm  tuberculin  (Moeller,  from  Dieu- 
doune). 

VI.  Acid-fast  Bacilli 

a.  Unheated — theoretical. 

ft.  Heated — timothy  hay,  grass  bacilli  (Moeller),  paratuberculin  iri- 
mescu,  dung,  pseudo-bovine. 

B.  Other  Formulas  than  Koch's 
I.  Human 

a.  Unheated.  Tuberculin  precipitated  by  alcohol  sixty  per  cent  from 
glycerinized,  nonneutralized,  nonpeptonized  bouillon,  and  added 
to  equal  parts  of  precipitated  orthophosphoric  acid  (one  per 
cent)  extract  of  tubercle  bacilli  of  standard  virulence,  and  dis- 
solved in  20  parts  of  diluent  (Beraneck). 

6.  Heated  to  100°  C. 

1.  More  glycerin,  no  meat  extract,  otherwise  as  in  0.  T.  (Yeseley). 

2.  Potassium-acid    phosphate,    ammonium    phosphate,    asparagin, 

glycerin,  added  to  bouillon  (De  Schweinitz  and  Dorset). 

3.  More  glycerin,  neutralized  with  NaHCOs,  not  boiled  and  re- 

duced in  vacuum  to  eight  per  cent  (Ponzio). 

II.  Bovine,  etc. 
All  theoretical. 

VARIETIES    OF    TUBERCULIN    USED    CLINICALLY 

The  varieties  of  tuberculin  that  have  been  most  used  clinically,  to- 
gether with  a  brief  description  of  their  preparation,  include : 

1.  Old  Tuberculin  (Koch). — A  boiled  (for  one  hour),  concentrated 
(on  a  water  bath  to  one  tenth  volume),  and  filtered  (through  a 
Chamberlain  filter)  "  beef  broth "  (containing  five  per  cent 
glycerin,  neutralized)  culture,  six  to  eight  weeks  old,  of  human 
tubercle  bacilli,  irrespective  of  virulence  or  of  strain,  but  usu- 
ally much  attenuated.  The  finished  product  contains  fifty  per 
cent  glycerin. 


516  SPECIFIC  TREATMENT 

2.  Tuberculin  R.    (Kocli). — An  imlieated   twenty-per-cent  glycerin 

emulsion  of  living,  virulent,  pulverized  tubercle  bacilli,  which 
have  first  been  extracted  with  water  (water  extract  named 
tuberculin  ohere),  containing  finally  in  each  cubic  centimeter 
10  mgm.  of  solid  substance. 

3.  Bacillen  Emulsion,   B.   E.    (Koch). — An  unheated   fifty-per-cent 

glycerin  emulsion  of  living,  virulent,  pulverized  tubercle  bacilli 
containing  5  mgm.  of  solid  substance  in  each  cubic  centimeter. 
The  coarser  particles  are  removed  by  centrifugalization.  Arlo- 
ing  believes  that  B.  E.  affects  breathing  more  than  old  tuber- 
culin, the  effects  of  B.  E.  last  longer  than  0.  T.,  and  that  the 
severity  depends  upon  the  virulence  of  the  bacilli  in  the  emul- 
sion and  in  the  animal. 

4.  Tuberculocidin    (T,    C.)    and    Antiphthisin    (Klebs).— The    old 

tuberculin  is  first  precipitated  with  bismuth  (tuberculocidin)  or 
potassium-bismuth-iodid  in  acetic  acid  (antiphthisin)  and  then 
with  alcohol. 

5.  "Watery   Extract"    (von  Ruck). — Tubercle  bacilli   are  washed 

with  water,  then  first  extracted  with  alcohol  and  ether  and  pul- 
verized, and  finally  extracted  with  water  at  50°  C. 

6.  Broth  Filtrate  (B.  F.)    (Denys). — The  unheated,  unconcentrated, 

filtered  (through  porcelain)  bouillon  culture  of  human  tubercle 
bacilli.  Denys  believes  this  is  ten  to  a  hundred  times  as  strong 
as  0.  T.,  but  Baldwin  has  proved  0.  T.  far  more  toxic  for 
guinea  pigs. 

7.  Beraneck's    Tuberculin. — A    twenty-per-cent    solution    of    equal 

quantities  of  the  unheated  precipitate  (by  sixty  per  cent  alco- 
Jiol)  of  a  culture  of  tubercle  bacilli  of  standard  virulence  on 
glycerinated,  nonneutralized,  nonpeptonized  bouillon  and  of  an 
orthophosphoric  acid  (one  per  cent)  extract  of  untreated  tuber- 
cle bacilli.     It  is  less  toxic  and  less  vaso-dilating  than  0.  T. 

Living  tubercle  bacilli  were  found  at  first  in  T.  R.  and  B.  E.  by 
Thellung,  in  B.  E.  by  von  Meissen,  and  in  T.  R.  by  Huber.  Many 
other  contaminating  bacteria  were  present  at  first  in  some  specimens 
(Baumgarten  and  Walz). 

Tuberculase,  tulase,  and  tulaselaktin  of  von  Behring  are  products 
of  or  altered  tubercle  bacilli,  whose  preparation  has  never  been  made 
known. 

No  accurate  method  of  standardization  of  tuberculin  has  yet  been 
found,  though  Doenitz,  Otto,  and  von  Lingelsheim  have  all  suggested 
methods,  the  first  two  using  tuberculous  with  subcutaneous,  the  latter 
healthy  guinea  pigs  with  intracerebral  injections. 


CHEMISTRY   OF  TUBERCULIN  517 

Comparison  of  the  strengths  of  the  various  tuberculins  were  made 
by  von  Behring  on  twenty  tuberculous  cattle,  and  he  found — 

1  part  T.  E.  =  3  parts  0.  T. 

1  part  tuberculin  purified  by  partial  alcohol  precipitation  =  4  to  6 
parts  0.  T. 

1  part  dried  and  pulverized  tubercle  bacilli  r=  4  to  5  parts  0.  T. 
1  part  nuclein  substance  =  3.5  to  4.5  parts  0.  T. 
1  part  tuberkulosamin  =  3  to  3.5  parts  0.  T. 
1  part  tuberculinic  acid  =:  3.5  to  4  parts  0.  T. 

C.  Spengler  states  bovine  tuberculin  causes  a  more  intense  skin  and 
"  organ  "  reaction  than  0.  T. 

As  Guinard  ('02)  remarks,  there  are  two  principal  objects  in  all 
the  work  on  tuberculin :  ( 1 )  To  free  the  tuberculin  of  its  dangerous 
constituents  and  to  preserve  its  useful  ones;  (2)  to  obtain  more  of  the 
latter  either  by  changing  the  media  used  for  growth  of  the  tubercle 
bacillus  or  by  employing  a  better  method  of  extraction.  On  the  whole, 
the  results  do  not  permit  us  to  think  that  a  single  tuberculous  extract 
bearing  the  name  of  tuberculin  is  able  to  be  taken  as  a  type  or  repre- 
sents a  fixed  product,  constant  in  its  composition  and  in  its  effects.  All 
probably  contain  the  specific  nucleic  acid.  What  Maragliano  said  in 
1898  is  still  true  to-day :  "  There  is  no  tuberculous  poison  entitled  to 
the  name  because  it  has  not  been  isolated  in  a  state  of  purity.  They 
have  always  been  in  glycerin  or  aqueous  solutions  under  different  forms 
of  precipitates,  dried  or  redissolved,  more  or  less  mixed  Avith  other 
albumoses."  Guinard  also  agrees  Avith  Arloing,  who  claims  that  how- 
ever slightly  the  microbic  products  are  treated,  the  active  element  may 
be  changed. 

CHEMISTRY    OF    TUBERCULIN 

Old  tul)erculin,  Kuehne  found,  differed  only  (luantitatively  from  the 
broth-culture  fluid.  It  gave  all  the  proteid  reactions,  but  resisted  heat 
(160°  C.  for  two  hours  in  50  per  cent  glycerin  solution),  so  differing 
from  all  kno\\7i  ali)uinosos  and  toxalbumins.  The  largest  amount  of 
active  substance  was  precij)itated  by  60  per  cent  alcohol,  and  tbe  crude 
and  precipitated  tuberculin  contained  on  an  average  18.86  per  cent  ash, 
chiefly  K  and  Mg  phosphate.  Kuehne  found  in  tuberculin  by  analysis  no 
alkaloids,  but  (1)  an  allniminate  (nucleoproteid),  (3)  a  peculiar  (aero-) 
albumose,  (3)  deutcro-albumose,  (4)  traces  of  peptone,  and  (5)  trypta- 
phane,  a  digestive  product. 

Ruppel,  who  examined  broth  filtrates  heated  only  to  30°  to  40°  C, 
found  no  specific  substance  differing  in  chemical  reactions  from  the 
proteids  in  the  original  broth. 


518  SPECIFIC  TREATMENT 

The  niuleoproteids  and  tubereulinic  acid  obtained  by  extracting 
bacilli  with  water,  with  glycerinated  water  (three  to  five  per  cent),  or 
with  weak  alkaline  solutions  contained  much  of  the  active  principle. 
This  substance  is  probably  in  proteid  combination,  and  while  peptic 
digestion  weakens  its  activity,  tryptic  digestion  destroys  it  (Baldwin 
and  Levene)  and  it  is  not  easily  dial3^zable.  Tuberculin  obtained  from 
the  bovine  bacilli  is  strongest,  that  from  the  human  weaker,  while  that 
from  the  avian  is  weaker  still  (Euppel),  a  fact  that  Smith  explains  by 
the  increased  alkalinity  of  the  bovine  cultures. 

It  has  long  been  held  that  if  only  a  more  virulent  toxin  co|ild  be 
obtained  from  the  tubercle  bacillus,  or  from  its  culture  fluid,  immuni- 
zation might  be  possible.  Much  work  by  Euppel,  Levene,  and  others 
has  resulted,  but  no  advance  has  been  made  along  this  line  for  some 
time,  and  it  is  now,  for  the  present,  at  least,  abandoned  (Ott,  '03). 

METHODS    OF    ADMINISTRATION 

Intravenous. — While  Koch  at  first  advised  tuberculin  to  be  admin- 
istered hypodermically,  in  1901,  when  he  announced  his  B.  E.  and  in- 
timated that  it  was  necessary  to  obtain  a  high  agglutinating  power  in 
the  blood  to  an  emulsion  of  pulverized  tubercle  bacilli,  he  suggested 
that  as  large  doses  of  B.  E.  caused,  when  given  subcutaneously,  ab- 
scesses, that  these  doses  be  given  intravenously.  Few,  however,  now 
accept  the  importance  Koch  at  that  time  attributed  to  agglutination 
as  the  index  of  immunity  and  intravenous  injection  of  tuberculin  may 
be  said  to  be  almost  never  used.  Eothschild,  M.  ('06),  and  Heermann 
('05)  have  reported  good  results  in  some  patients  with  this  method, 
and  Denys  has  used  it.  The  dose  is  one  tenth  the  amount  given  sub- 
cutaneously, and  the  fact  that  the  best  immunity  has  been  obtained 
with  living  bacilli  by  this  method  should  arrest  attention. 

Oral. — Tuberculin  has  been  administered  in  nearly  every  conceiv- 
able way.  Freymuth  ('05)  has  given  it  per  os  in  the  form  of  kaolin- 
coated  pills,  after  neutralization  of  the  gastric  juice  with  sodium  bicar- 
bonate to  avoid  digestion  in  the  stomach,  while  Klebs  takes  no  account 
of  this  factor.  Hubs  ("07),  who  reacted  severely  to  small  doses  sub- 
cutaneously (100°  F.  after  0.00005  0.  T.),  took  1  gm.  0.  T.  by  mouth 
with  and  without  neutralizing  the  gastric  juice  with  a  large  amount 
of  sodium  bicarbonate,  and  yet,  although  he  had  taken  20,000  times 
the  foregoing  minimum  dose,  it  had  no  effect  whatsoever.  Eecent  work 
on  serums  has  shown  that  antibodies  in  serums  are  absorbed  un- 
changed from  the  alimentary  tract  only  during  the  first  two  weeks 
of  life  or  when  the  epithelium  is  injured,  but  Calmette  and  Guerin 
('07)  have  succeeded  in  vaccinating  calves  by  feeding  them  tuberculous 


METHODS  OF   ADMINISTRATION  519 

milk,  while  Figari  and  Maragliano  claim  to  have  had  excellent  results 
in  guinea  pigs  from  oral  administration  of  blood  clots  from  immunized 
calves  and  horses.  The  work  of  Levene,  Baldwin,  and  Kinghorn  shows 
that  tuberculin  is  affected  by  the  digestive  processes  in  the  stomach 
and  intestines.  Furthermore,  it  is  impossible  to  gauge  accurately  the 
dose  by  this  method  (Loewenstein  and  Koehler)  or  by  inhalation,  and 
consequently  severe  reactions  may  occur  when  least  expected  and  hyper- 
sensibility  result. 

Inhalation. — Kapralik  ('04)  and  von  Schroetter  ('04)  have  em- 
ployed tuberculin  by  inhalation  in  the  form  of  a  spray,  first  suggested 
by  Moeller,  a  method  requiring  large  doses  and  incurring,  therefore, 
much  expense.  Bandelier  obtained  no  results  from  inhalations,  and 
Huhs  thinks  them  of  little  value. 

Jacobs  injected  tuberculin  intratracheally,  to  enable  a  large  quan- 
tity to  reach  the  site  of  the  lesion,  and  was  severely  criticised  by  his 
confreres.  Tuberculin  in  solution  is  well  absorbed  from  the  lungs, 
but  the  dosage  is  inexact,  and  what  can  be  hoped  from  saturating 
with  tuberculin  an  organ  which  already  contains  much  of  it  is  difficult 
to  see. 

Dermic. — Administration  by  rubbing  into  the  skin  is  only  of  value 
in  hypersensitive  individuals  and  children.  It  has  marked  limitations 
which  Spengler  ('03)  has  noted,  and  further  may  be  accompanied  by 
disagreeable  skin  reactions.  Spengler  rubs  into  the  forearm  of  patients 
who  are  hypersensitive  1,  5,  and  10  mgm.  at  intervals  of  two  to  four 
days.  In  two  weeks  the  subcutaneous  injections  can  be  recommenced. 
Proper  dilutions  render  this  method  entirely  unnecessary. 

The  rectal  and  the  intrapulmonary  injection  (Livierato)  of  tuber- 
culin need  only  to  be  mentioned  to  be  condemned. 

Subcutaneously. — Tuberculin  injected  subcutaneously  is  nearly  at 
once  absorbed  by  the  lymphatics.  It  is  of  interest  to  bear  in  mind  that 
the  large  mononuclear  cells  which  seem  chiefly  concerned  in  the  process 
of  immunization  in  tul^erculosis  are  probably  derived  from  the  endo- 
thelial cells  of  the  lymph  and  blood-vessels,  which  are  directly  stimu- 
lated by  this  method,  and  stimulated  most  intensely  at  a  point  far 
distant  from  the  area  of  infection.  Beraneck,  however,  opposes  this 
view,  and  believes  tuberculin  should  be  injected  directly  into  or  imme- 
diately about  the  focus.  A  careful  consideration  of  all  these  methods 
unquestionably  leads  to  the  conclusion  that  the  subcutaneous  method 
is  by  far  the  most  exact,  the  most  reliable,  the  most  elastic  (adaptable), 
and  the  most  efficacious.  The  same  arguments  apply  here  that  are  used 
in  favor  of  the  hypodermic  administration  of  drugs.  For  tiiese  reasons 
the  discussion  here  is  limited  entirely  to  the  subcutaneous  administration 
of  tuberculin. 


520  SPECIFIC  TREATMENT 


DILUTIONS 


Tuberculin  in  man}^  instances  produces  at  the  site  of  injection  the 
four  classical  signs  of  inflammation — tumor,  roboi\  calor,  and  dolor. 
It  is  natural  to  presuppose  that  the  tissues  are  less  resistant  to  infection 
at  this  point,  but  care  in  regard  to  asepsis  always  prevents  suppuration 
unless  large  doses  of  B.  E.  have  been  given,  when,  in  sj)ite  of  asepsis, 
local  sterile  abscesses  may  occur.  All  emulsions  or  vaccines  of  tubercle 
l)acilli  should  always,  therefore,  be  well  diluted,  but  this  is  not  neces- 
sary with  many  other  forms  of  tuberculin. 

Preservation  in  Dilution. — In  all  cases,  except  where  large  doses  of 
tuberculin  are  used,  it  is  necessary  to  dilute  the  original  tuljerculin,  as  at 
present  few  tuberculins  are  put  on  the  market  in  a  form  sufficiently  di- 
luted for  the  earlier  doses.  Furthermore,  it  lu\s  not  yet  been  determined 
how  long  the  high  dilutions  retain  tlieir  strength,  especially  when  a  small 
percentage  of  some  antiseptic  has  been  added.  High  dilutions  apparently 
retain  their  strength  for  two  weeks,  and  it  is  not  improbable  that  they 
may  do  so  for  a  much  longer  period,  but  until  sufficient  proof  of  this  is 
adduced  they  should  be  made  up  fresh  every  two  weeks.  Jacquerod  says 
a  ten-per-cent  solution  degenerates  only  after  six  weeks. 

It  is  best  to  keep  the  tuberculin  as  well  as  all  dilutions  in  a  cool 
place  (ice  box)  protected  from  light.  In  making  the  dilutions  the 
greatest  care  should  be  used  not  to  contaminate  the  original  tul)erculin, 
which  should  be  in  a  paraffined,  rubber-stoppered,  dark  bottle.  If  con- 
taminations do  occur — i.  e.,  if  the  original  tuberculin  becomes  more 
cloudy  (some  forms  are  never  clear) — it  should  be  discarded  and  not 
used.  With  care  this  is  practically  never  necessary,  and  no  instance 
of  any  sort  has  ever  suggested  to  the  writer  that  the  tuberculin  he  was 
using  should  be  resterilized. 

Method  of  Diluting. — The  dilution  of  tuberculin  is  a  comparatively 
simple  process  that  demands  little  previous  experience  but  great  exact- 
ness. If  at  any  time  during  the  process  of  dilution  a  question  of  error 
arises,  it  is  well  to  throw  aside  the  dilutions  and  start  anew. 

The  instruments  necessary  for  making  dilutions  are  a  1-c.c.  glass 
pipette,  graduated  into  hundredths  of  a  cubic  centimeter,  Avith  a  scale 
at  least  15  cm.  long  and  a  long,  conical  10-c.c.  graduate.  These  should 
always  be  boiled  before  use,  though  some  recommend  keeping  them  in 
a  disinfecting  solution  (alcohol,  etc.)  and  rinsing  with  a  diluent  before 
using.  A  glass  syringe  with  a  capacity  of  1  c.c,  with  a  long,  narrow 
barrel,  graduated  into  hundredths  of  a  cubic  centimeter,  is  mi;ch  easier 
to  use,  and,  if  accurately  graduated,  is  more  exact.  It  matters  little, 
however,  whether  either  the  pipette  or  syringe  be  accurately  graduated, 
provided  that  the  same  instrument  be  used  each  time.     This  syringe 


DILUTIONS  521 

is  also  the  best  for  use  in  giving  tuberculin.     The  actual  dose  is  of  far 
less  importance  than  the  relative  dose.     If  a  syringe  be  used,  it  should 


Fig.  147. — Ix-ti:umextarium  for  Tubercxtlix  Injections.  From  left  to  right: 
Sterilizer,  large  (1,000  c.c.)  and  small  (100  c.c),  measuring  cylinders,  flask  with 
sterile  water,  bowl,  three  small  bottles  holding  tuberculin  stock  solutions  (B.  E. 
and  B.  F.).  On  shallow  glass  dish  with  hj-podermic  syringe,  holding  1  c.c, 
subdivided  into  lOOths  c.c.     In  front  calibrated  pipette. 

be  freed  carefully  from  water  and  rinsed  several  times  in  the  solution 
to  be  diluted  (see  Fig.  147). 

Diluents. — The  best  diluent  is  probably  one  fourth  per  cent  phenol 
in  physiologic  saline  solution.  It  should  be  carefully  boiled  and  filtered 
from  time  to  time.  Phenol  may  be  replaced  by  lysol  in  the  same 
strength.  For  emulsions  of  the  tubercle  bacillus,  which  should  always 
be  shaken  before  using,  Koch  recommended  that  the  diluent  should  be 
physiologic  salt  solution,  but  the  ordinary  diluent  may  be  used. 

Estimating  Dilutions. — When  a  table  for  dilutions  is  not  at  hand, 
the  easiest  method  is  to  decide  what  content  per  cubic  centimeter  is 
desired.  For  example,  if  10  c.c.  of  a  diluent,  in  which  1  c.c.  =:  0.000001 
c.c.  of  the  original  tuberculin,  be  required,  with  a  pipette  or  syringe 
0.1  c.c.  of  the  original  tuberculin  is  taken  and  the  diluent  added  until 
10  c.c.  is  reached.  Then  as  0.1  c.c.  is  in  10  c.c,  1  c.c.  must  contain 
0.01  c.c.  Repeating  this,  a  solution  is  obtained  of  which  1  c.c.  =  .0001 
c.c.  of  the  original  tuberculin.  The  amount  desired  of  the  final  solution 
determines  how  much  of  this  solution  should  be  used.     As  it  is  wished 


522 


SPECIFIC  TREATMENT 


to  get  10  c.c.  of  a  solution  in  which  1  c.c.  =  .000001,  multiply  .000001 
by  10,  obtaining  .00001.  This  amount  of  tuberculin  is  contained  in  0.1 
c.c.  of  the  last  solution,  which  is  measured  out  and  diluted  up  to  10  c.c, 
which  gives  the  required  strength — 1.  e.,  1  c.c.  =  .000001  of  the  original 
tuberculin.  This  process  may  be  continued  until  any  required  dilution 
be  obtained.  By  adding  diluent  until  a  volume  of  100  c.c.  is  reached, 
fewer  intervening  dilutions  are  necessary.  It  is  unwise  to  attempt  to  meas- 
ure less  than  1  c.c.  when  making  dilutions.  The  accompanying  schema, 
in  which  grams  are  equivalent  to  cubic  centimeters,  has  long  been  used  at 
the  Adirondack  Cottage  Sanitarium,  and  has  given  much  satisfaction: 


Variety 
Strengt 

O.  T.  OR  B.  F. 

1  G.  TO  1   C.C. 

T.  R. 

.01  G.  TO   1   C.C. 

B.  E. 

.005  G.  TO  1  r.c. 

Solu- 
tion 
No. 

To  make  10  c.c.  of 

solutions  of  following 

strengths — 

Take 

Take 

Take 

0 

1  g.  to  1  C.C. 

10  c.c.  Tuberculin. 

i 

I 

.Ig.  tolc.c. 

1  c.c.  Tuberculin. 
9  c.c.  Diluent. 

11 

.01  g.  to  1  c.c. 

0.1  c.c.  Tuberculin 
9.9  c.c.  Diluent. 

or 
1  c.c.  Solution  I. 
9  c.c.  Diluent. 

10  c.c  Tuberculin. 

III 

.001  g.  to  1  c.c. 

0.1  c.c.  Solution  I. 
9.9  c.c.  Diluent. 

or 
1  c.c.  Solution  II. 
9  c.c.  Diluent. 

1  c.c.  Tuberculin. 
9  c.c.  Diluent. 

2  c.c.  Tuberculin. 
8  c.c.  Diluent. 

IV 

.0001  g.  to  1  c.c. 

0.1  c.c.  Solution  II 
9.9.  c.c.  Diluent. 

or 
1  c.c.  Solution  III. 
9  c.c.  Diluent. 

0.1  c.c.  Tuberculin 
9.9  c.c.  Diluent. 

or 
1  c.c.  Solution  III. 
9  c.c.  Diluent. 

0.2  c.c.  Tuberculin. 
9.8  c.c.  Diluent. 

or 
1  c.c.  Solution  III. 
9  c.c.  Diluent. 

V 

.00001  g.  to  1  c.c. 

O.lc.c.Solutionlll 
9.9  c.c.  Diluent. 

or 
1  c.c.  Solution  IV. 
9  c.c.  Diluent. 

O.lc.c.Solutionlll 
9.9  c.c.  Diluent. 

or 
1  c.c.  Solution  IV. 
9  c.c.  Diluent. 

0.1  c.c.  Solution  III 
9.9  c.c.  Diluent. 

or 
1  c.c.  Solution  IV. 
9  c.c.  Diluent. 

VI 

.000001  g.  to  1  c.c. 

0.1  c.c.  Solution  IV 
9.9  c.c.  Diluent. 

or 
1  c.c.  Solution  V. 
9  c.c.  Diluent. 



0.1  c.c.  Solution  IV 
9.9  c.c.  Diluent. 

or 
1  c.c.  Solution  V. 
9  c.c.  Diluent. 

PREPARATION   FOR   INJECTIONS  523 

PREPARATION    FOR    INJECTIONS 

Cleansing  of  Skin. — The  area  of  skin  selected  should  be  vigorously 
rubbed  with  alcohol  both  before  and  after  the  injection.  No  other 
cleansing  is  necessary,  and  the  use  of  antiseptics,  ether,  cotton,  col- 
lodion, etc.,  is  superfluous.  In  thousands  of  injections  made  by  the 
writer,  alcohol  alone  has  been  used  and  no  infection  has  ever  oc- 
curred. 

Needles. — The  needles  used  should  be  very  fine,  should  be  rinsed  in 
alcohol  or  ether  after  using  and  in  boiling  water  before  using.  They  need 
not  be  boiled,  nor  need  they  be  kept  in  alcohol  if  they  are  not  used 
for  any  other  purpose.  The  platinum-iridium  needles  used  by  some 
(Holdheim)   are  unnecessary. 

Accidental  Inoculation. — When  tuberculin  is  given  to  a  large  num- 
ber of  patients,  great  care  should  be  taken  to  avoid  ejecting  a  spray 
of  tuberculin  into  the  air  when  forcing  out  bubbles  of  air,  as  reactions 
have  been  produced  in  this  way.  The  boiling  water  used  for  rinsing 
the  syringes  between  injections  should  always  be  fresh,  and  graduates 
or  pipettes  used  for  making  dilutions  should  never  be  placed  in  this 
water,  nor  should  the  water  drawn  up  into  the  syringe  be  ejected  back 
into  this  pan.  The  physician,  if  tuberculous,  should  always  wash  his 
hands  after  handling  tuberculin. 

Site  of  Injection. — During  the  rubbing  for  cleansing,  the  site  should 
be  examined  to  see  that  it  is  free  from  indurations  left  from  previous 
injections.  The  occurrence  of  these  indurations  vary  both  for  indi- 
viduals and  for  the  form  of  tuberculin  used. 

The  usual  site  is  4  to  8  cm.  from  the  midline  opposite  the  seventh 
to  the  tenth  dorsal  spines.  The  skin  is  usually  thick,  less  vascular, 
easily  movable,  and  less  sensitive  in  this  area.  It  should  be  given  well 
under  and  not  in  the  skin. 

Beraneck  believes  that  his  tuberculin  acts  more  favorably  when 
injected  near  or  directly  into  the  focus  in  surgical  tuberculosis,  as  it 
produces  an  increased  phagocytosis  and  possibly  sets  free  bacteriolytic 
ferments  from  the  cells.  He  has  not  advocated  intrapulmonary  injec- 
tions.    Crocker  and  Pernet  advise  local  injection  in  lupus. 

The  toxin  enters,  often  continuously,  into  the  circulation  about  the 
tuberculous  foci,  and  the  contiguous  cells  are  constantly  stimulated. 
In  tuberculin  treatment  it  is  injected  at  intervals  into  the  lymphatics 
(subcutaneous),  far  removed  from  the  disease  foci.  The  latter  process 
may  call  into  play  the  whole  body,  especially  the  lymphatic  system, 
while  the  action  of  the  former  may  be  limited  to  the  circulatory  system, 
possibly  of  a  limited  area. 


524  SPECIFIC  TREATMENT 

DOSAGE    AND    INTERVAL 

General. — The  crucial  point  in  the  tuberculin  treatment  is  the  selec- 
tion of  the  dose  and  interval.  The  literature  of  the  period  of  tuberculin 
delirium  (1890-91)  is  filled  with  reports  of  patients  who  were  excessively 
overdosed,  and  in  some  instances  undoubtedly  killed  by  overdosing  with 
tuberculin.  The  few  men  who  continued  to  use  tuberculin  were  those 
who  from  the  first  employed  much  smaller  doses  than  were  in  current 
use.  To  Guttmann  and  Ehrlich,  to  Goetsch  particularly,  to  Denys,  to 
Trudeau,  and  to  Wright  do  we  owe  the  present  recognition  of  the  value 
of  small  doses.  Two  men,  hoAvever,  Denys  and  W^right,  deserve  special 
mention  in  this  connection.  Denys  in  his  book,  "  Le  Bouillon  Filtre," 
has  given  the  best  exposition  of  the  clinical  value  of  beginning  with 
small  doses  of  tuberculin  in  all  forms  of  tuberculosis,  and  Wright, 
basing  his  opinion  on  his  studies  of  the  opsonic  index,  has  emphasized 
the  great  benefit  to  be  derived  from  small,  repeated,  or  very  slightly 
increased  doses  of  tuberculin  in  surgical  tuberculosis.  The  method  of 
administration  of  tuberculin  is  far  more  important  than  the  variety  of 
tuberculin,  and  he  who  fails  to  consider  that  tuberculin  is  a  most  potent 
poison,  is  a  dangerous  man.  Too  great  care  cannot  be  exercised,  and 
carelessness  may  be  equivalent  to  homicide.  A  beginner  who  presumes 
on  his  inexperience  is  likely  to  have  woeful  results. 

Beginning  Lose. — The  first  dose  of  tuberculin  should  be  so  selected 
that  all  possibility  of  reaction  is  excluded.  Koch,  C.  Spengler,  Bande- 
lier  and  Roepke,  and  others  have  advocated  that  slight  reactions  (under 
100.4°  F.)  are  necessary  for  the  best  results,  while  the  vast  majority 
of  observers  endeavor  to  avoid  reactions  whenever  possible,  but,  in  spite 
of  all  precautions,  slight  reactions  will  occasionally  occur  during  the 
course  of  the  treatment.  In  all  patients  who  have  recently  been  sub- 
jected to  the  tuberculin  test,  in  all  who  have  a  subfebrile  temperature, 
extensive  pulmonar}^  involvement,  a  nervous  temperament,  or  compli- 
cations, more  care  about  the  dosage  should  be  exercised  at  first.  One 
patient,  a  well-nourished,  strongly  built  woman  aged  twenty-four  years, 
with  extensive  infiltration  and  slight  apical  consolidation  of  the  left 
lung,  reacted  to  0.0000001  c.c.  of  broth  filtrate  (B.  F.).  and  for  four 
months  was  unable  again  to  reach  so  large  a  dose.  Another  patient, 
a  strongly  built  male,  aged  forty,  with  extensive  signs  of  infiltration 
in  both  lungs,  was  given  without  reaction  a  first  dose  of  0.000005  c.c. 
B.  F.,  and  in  six  weeks  with  biweekly  doses  reached  0.001  c.c.  The 
susceptibility  to  tuberculin  varies  greatly  both  in  different  patients 
as  well  as  in  the  same  individual  at  different  times,  and  cannot  be 
estimated  accurately  beforehand  either  irom  the  physical  signs,  the 
symptoms,   or,   indeed,  from   any  data   at   our   command.      Such   facts 


DOSAGE  AND   INTERVAL  525 

emphasize  the  great  necessity  for  careful  individual  treatment  of  each 
patient,  and  beginners  especially  should  studiously  avoid  producing  any 
evidence  of  reaction. 

The  size  of  the  first  dose  has  been  directly  affected  by  the  idea  that 
the  tuberculin  treatment  should  extend  over  many  months,  and  the  final 
dose  still  influences  many  men  in  the  selection  of  the  first  dose.  This 
is  especially  true  in  sanatoriums,  where  oftentimes  both  patient  and 
physician  feel  as  if  they  must  begin  with  as  large  a  dose  as  possible 
and  hurry  on  until  a  large  final  dose,  often  1  c.c,  is  reached.  (See 
Duration  of  Treatment.)  This  is  based  on  wrong  premises,  as  all 
patients  need  not  be  carried  to  the  same  dose  to  derive  equal  bene- 
fit, and  the  final  dose  should  have  no  influence  on  the  first.  It  is 
often  well,  as  Sahli  also  holds,  to  repeat  the  first  dose,  especially  if 
there  be  any  doubt  about  its  causing  a  reaction.  The  initial  subcu- 
taneous dose  for  the  tuberculins  most  frequently  used  are  given  on 
pages  540-541. 

Interval. — Wlien  first  used,  tuberculin  was  given  every  day,  a  method 
soon  found  to  be  wrong.  Many  to-day,  however,  advise  that  at  first 
it  be  given  every  day  or  every  other  day,  and  later  every  three  or  four 
days.  As  even  slight  reactions  may  not  be  manifested  until  as  late  as 
forty-eight  or  even  sixty  hours,  the  danger  of  giving  tuberculin  oftener 
than  every  three  or  four  days  (biweekly)  is  apparent.  Many  patients, 
especially  those  susceptible,  often  do  better  by  taking  but  one  dose  in 
seven  to  ten  days.  This  more  nearly  corresponds  to  the  time  required 
for  the  formation  of  antibodies,  and  fits  in  with  the  clinical  work  of 
Wright  and  others.  When  large  doses  (0.5  c.c.  B.  F.  or  0.  T.,  or  2  mgm. 
B.  E.)  are  reached,  an  interval  of  seven  to  fourteen  days  is  none  too 
long.  Furthermore,  when  tuberculin  is  given  at  too  short  intervals, 
hypersensibilit}'  may  occur. 

Increase  of  Dose. — The  first  dose,  if  sufficiently  small,  requires  little 
consideration,  but  the  key  to  successful  tuberculin  treatment  lies  in  a 
proper  gi'adation  of  the  doses.  It  is  here  that  experience  is  necessary 
and  judgment  at  times  difficult,  for  it  is  now  well  recognized  that 
objective  reactions  are  not  necessary  and  should  be  avoided.  The  for- 
mation of  antibodies  requires  time,  and  a  quick  increase  is,  therefore, 
of  little  avail,  Avhile  some  hold  that  increase  beyond  a  very  small  dose 
is  of  no  value  (Wright),  but  to  get  tuberculin  immunity,  a  steady  in- 
crease without  reaction  must  be  maintained.  The  most  important  rule 
to  be  remembered  is  that  too  little  never  injures,  while  too  much  tuber- 
culin may  provoke  a  serious  reaction  and  hypersensibility  (see  p.  538). 
Whenever,  therefore,  a  question  about  a  larger  or  smaller  dose  arises, 
it  is  well  to  choose  the  latter,  for  when  hypersensibility  is  once  pro- 
voked,   it   may   be    impossible   to   produce    tuberculin    immunity,    and 


526  SPECIFIC  TREATMENT 

at  least  for  some  months  the  treatment  may  have  to  he  discontin- 
ued (p.  549).  In  mild  instances  it  may  be  sufficient  to  omit  sev- 
eral doses,  to  reduce  markedly  the  next  dose  and  to  lengthen  the 
interval. 

The  results  of  any  single  dose  of  tuberculin,  well  within  the  limits 
of  reaction,  have  been  most  difficult  to  estimate.  The  administration 
of  tuberculin  has  been,  and,  in  the  hands  of  most  observers,  still  is 
undoubtedly  empirical  in  the  sense  that  they  have  at  hand  no  practical 
means,  either  clinical  or  laboratory,  of  estimating  exactly  what  the  next 
dose  should  be  from  the  effects  produced  by  the  last. 

Laboratoby  Method. — The  indications  for  increasing  the  dose  may 
be  based  on  clinical  or  laboratory  observations  or  on  both  together. 
The  only  laboratory  method  of  any  value  is  that  devised  by  A.  E. 
Wright  ('04)  and  based  on  the  ojisonic  index.  The  long  apprenticeship 
necessary  to  acquire  the  teclmic,  the  time-consuming  details,  and  the 
many  chances  for  error  inherent  in  the  determination  of  the  "  opsonic  in- 
dex," make  AVright's  method  of  little  practical  value  where  tul)erculin  is 
given  to  a  large  number  of  patients,  while  in  regard  to  pulmonary  tuber- 
culosis he  states  that  it  is  of  no  value,  except  in  the  very  earliest  stages. 
Eecent  work  at  Cambridge  (England)  would  seem  to  show  that  to  avoid 
error  it  is  necessary  to  count  1,000  cells,  and  inasmuch  as  it  is  necessary 
to  compute  the  index  every  other  day  for  four  or  five  times  following 
a  dose  of  tuberculin  to  study  its  effect,  the  magnitude  of  the  work  is 
appalling.  Wright  has,  however,  emphasized  the  value  of  small  repeated 
doses  of  tuberculin,  especially  in  surgical  tuberculosis.  He  strives  to 
increase  the  tuberculo-opsonic  content  of  the  blood  and  totally  dis- 
cards all  idea  of  a  tuberculin  immunity,  though  some  is  probably 
acquired  (p.  525).  Wright's  opsonic  index  method,  while  not  prac- 
tical, is  a  great  step  in  the  right  direction,  inasmuch  as  it  attempts 
to  estimate  the  results  of  each  dose  of  tuberculin.  (For  technic,  see 
Appendix.) 

Clinical  Method. — Careful  clinical  observations  afford  sufficient 
data  for  the  proper  administration  of  tuberculin  when  tuberculin  im- 
munity is  the  object.  Such  methods  are,  however,  gross,  and  all  have 
to  acknowledge  that,  in  spite  of  the  most  careful  observations,  occasional 
reactions  will  occur.  Many  have  attempted,  b}^  studying  the  various 
fluids  and  excreta  of  the  body,  to  determine  the  proper  dosage.  The 
urine  has  afforded  no  help  and  the  sputum  has  been  studied  in  regard 
to  the  number  of  tubercle  bacilli,  their  virulence,  morphology,  and  the 
number  found  intracellular  (phagocytosis),  but  none  of  this  is  of  avail 
in  regard  to  the  amount  of  the  next  dose.  The  blood  has  yielded  no 
help  either  from  a  study  of  the  erythrocytes,  of  the  leucocytes  (total 
or  differential  count,  Arneth's   ('05)  neutrophilic  picture,  except  after 


DOSAGE  AND   INTERVAL  527 

a  reaction  ^),  or  from  a  study  of  the  senim  in  regard  to  agglutinization. 
The  opsonic  index  has  been  discussed,  and  in  pulmonary  tuberculosis, 
where  tuberculin  immunity  is  the  object,  it  can,  as  Kinghorn  and 
Twitchell  have  shown,  be  ignored.  The  index  fluctuates,  and  whether 
tuberculin  be  given  at  any  stage  of  a  negative  or  positive  phase,  is  as 
likely  to  go  up  as  down.  The  blood-pressure  aids  little  (Bauer,  Miller). 
In  fact,  after  careful  consideration  of  the  whole  question,  we  are  forced 
to  rely  chiefly,  if  not  entirely,  on  the  symptoms,  general  and  localizing, 
the  temperature,  pulse,  weight,  and  strength,  and  the  phenomena  that 
occur  at  the  site  of  injection. 

Time  of  Injection. — In  order  to  observe  best  these  s3^mptoms,  it  is 
wise  to  give  the  injections  in  the  evening  or  afternoon,  and  not  in  the 
morning  as  some  advise  (Sahli,  '06;  Bandelier  and  Eoepke,  '08).  An- 
other advantage  of  giving  the  injections  late  in  the  day  is  the  oppor- 
tunity afforded  for  observing  on  the  day  of  injection  the  maximum 
temperature,  which  in  a  number  of  instances  precludes  the  dose.  Sahli's 
contention  that  the  normal  morning  remission  may  obscure  a  slight 
rise  when  tuberculin  is  given  in  the  afternoon  or  evening  is  probably 
based  on  the  fact  that  he  usually  administers  it  during  the  morn- 
ing, but  Beraneck's  tuberculin  may  cause  a  quicker  rise  of  tem- 
perature. Whether  the  minimal  or  maximal  temperature  is  affected 
first  would  decide  this  point,  as  the  reaction  usually  begins  about 
ten  or  twelve  hours  after  the  dose.  When  given  late  in  the  day, 
the  afternoon  or  evening  temperature  on  the  following  day  is  much 
more  frequently  and  more  violently  affected  than  the  morning  tem- 
perature. 

Record  of  Treatment. — The  observation  of  these  symptoms  has  to 
be,  in  many  cases,  at  least,  relegated  to  the  patient,  and  he  should  be 
made  aware  of  what  spnptoms  to  note,  as,  like  most  men,  even  when 
trained,  he  will  observe  only  what  he  looks  for.  He  should  be  supplied 
with  a  reliable  thermometer,  taught  how  to  take  his  oral  temperature, 
and  required  to  take  it  at  least  three  times  a  day,  on  awaking,  at  4 
and  at  8  p.m.,  and  at  any  other  times  of  the  day  he  may  feel  that  he 
has  some  elevation  of  temperature,  or  at  the  time  of  the  individual  daily 
maximum,  for  one  week  previously  as  well  as  throughout  the  treatment. 
When  restless  at  night  after  tuberculin  he  should  also  take  his  tem- 
perature. These  should  all  be  noted  in  a  booklet,  together  with  the 
presence  or  absence  of  the  symptoms  mentioned  below,  where  are  repro- 
duced specimen  pages  of  a  booklet  used  by  the  writer  with  considerable 
satisfaction  for  some,  time. 

I  Arneth  holds  that  his  blood  picture  is  of  some  value  in  estimating  the  dose,  but 
this  lacks  confirmation. 


528  SPECIFIC  TREATMENT 

This  little  record  book  is  intended  to  aid  your  physician  to  give  you 
tuberculin  rnore  carefully,  moi*e  intelligently,  and  more  scientifically.  He 
must  depend  upon  your  accuracy,  which,  accordingly,  is  closely  connected 
with  the  benefits  you  will  derive  from  this  line  of  treatment.  Put  down 
no  statement  that  is  not,  according  to  the  best  of  your  knowledge  and 
belief,  true  in  every  particular  and  not  in  any  way  misleading. 

To  render  the  temperature  records  accurate,  it  is  never  wise  to  leave 
the  thermometer  in  your  mouth  less  than  five  minutes,  and  in  cold 
weather  or  out  of  doors  the  mouth  should  be  kept  closed  for  fifteen  min- 
utes, the  thermometer  then  inserted  and  left  in  place  for  ten  to  fifteen 
minutes. 

If  you  are  taking  the  tubercidin  treatment,  the  list  of  symptoms 
should  be  carefully  scanned.  The  signs  "  +  "  and  "  0  "  may  be  used  to 
indicate  "  present "  and  "  absent."  If  j-our  back  or  arm,  wherever  you 
receive  the  injection,  does  not  attract  your  attention,  put  down  "  0 " 
opposite  "  At  Site  of  Injection."  Othemuse  indicate  what  symptoms  you 
have  at  this  spot.  If  you  feel  as  usual  and  have  none  of  the  "  General 
Symptoms,"  indicate  this  by  an  "  0 "  opposite  "  General  Symptoms." 
Otherwise  put  "  +  "  opposite  each  symptom  that  occurs  and  "  0  "  oppo- 
site the  remainder.  The  same  should  be  done  with  the  "  Localizing  Symp- 
toms." When  coug'h,  expectoration,  or  strength  are  said  to  be  increased 
or  decreased,  it  means  in  comparison  with  the  usual  amount.  The  weight 
should  be  recorded  once  a  week,  and  the  pulse  noted  only  when  it  varies 
from  the  usual  rapidity.  The  temperature  should  be  taken  in  the  morn- 
ing in  bed  before  rising  and  before  the  teeth  have  been  cleaned.  If  by 
experience  the  hig'hest  or  lowest  temperatures  occur  at  other  times  than 
those  indicated  (7  a.m.,  4  p.m.,  and  8  p.m.),  these  hours  should  be  changed 
to  the  hours  at  which  the  minimum  and  maximum  occur.  "  Low  "  and 
"  high  "  are  often  simple  repetitions  of  these  temperatures,  but  they  are 
useful  to  your  physician.  When  your  temperature  reaches  100°  F.  and 
remains  at  this  point  two  hours  you  should  go  to  bed,  unless  otherwise 
directed  by  your  physician.  Always  go  to  bed  if  you  feel  bad  or  have  any 
pronounced  symptoms.  "  In  bed "  means  whether  you  spent  the  day, 
morning,  or  afternoon  in  bed.  "  Exercise "  means  how  long  each  day 
you  exercise,  which  is  usually  indicated  by  the  amount  taken  morning 
and  afternoon,  e.  g.,  "  ^  hour "  would  mean  one  half  hour's  exercise 
morning  and  afternoon.  Exercise  shovdd  be  greatly  restricted  the  day 
of  the  injection,  and  none  taken  the  following  day  until  late  in  the  after- 
noon, when,  if  no  symptoms  have  arisen,  a  less  amount  than  usual  may 
be  taken. 

Be  perfectly  frank  and  honest  with  your  physician.  Tell  him  of  any 
act  of  overexertion,  and  if  any  symptoms  ever  occur  which  are  not  men- 
tioned in  this  book,  be  sure  to  call  his  attention  to  them.  It  is  only  by 
mutual  confidence  that  the  best  results  can  be  obtained.  You  are  both 
partners  in  the  most  serious  business  of  your  life,  and  partners  should 
discuss  every  detail  of  their  affairs,  which,  however,  should  not  be 
divulged  to  the  rest  of  the  world. 


DOSAGE   AND   INTERVAL 


529 


Date 

Dose 

At  Site  of  Injection: 

Paiu 

General  Symptoms : 

Rash    

Localizing  Symptoms  : 

"                 8  P.M 

"               High. 

Pulse 

"Weight 

Strength :  Increased 

.  .•.  .    . 

Typical  Beaction. — In  a  typical  tuberculin  reaction,  nsnally  ten  to 
eighteen  hours  after  the  injection  the  patient  begins  to  feel  feverish 
(possibly  chilly  at  tirst).  heavy,  and  dull,  e.xperiences  lassitude  and  has 
slight  elevation  of  temperature,  often  detected  in  the  urine  stream  or 
rectum  Ijefore  in  the  mouth.  These  symptoms  are  rapidly  aggravated, 
and  in  a  short  time  the  ])atient  feels  so  ill  that  he  is  forced  to  go  to 


530  SPECIFIC  TREATMENT 

bed  with  pains  in  the  back,  legs,  and  head,  which  are  often  severe. 
The  tendency  to  cough  may  be  increased,  oppression  may  be  felt  in  the 
chest,  and  the  expectoration  may  be  increased.  The  temperature  may 
rise  to  103°  F.  or  higher,  the  pulse-rate  reach  120  or  over,  the  urine 
may  be  increased,  with  a  slight  trace  of  albumen  or  a  diazo-reaction, 
and,  on  the  whole,  the  patient  is  ill.  These  sj'mptoms  persist  for  eight 
to  twelve  hours,  and  usually  on  the  following  day  the  patient  feels  a 
little  weak,  but  otherwise  all  right.  In  a  few  instances  the  reaction  is 
delayed  for  forty  to  forty-eight  hours,  and  in  others  the  rise  of  tem- 
perature is  less  (100°  F.),  but  persists  for  several  days,  while  the 
symptoms  may  he  very  severe. 

Skin  Reaction. — The  classical  signs  of  inflammation  occur  at  the 
point  of  injection,  persist  for  one  or  two  days,  but,  except  with  B.  E., 
never  go  on  to  suppuration  if  asepsis  has  been  preserved.  Sites  of  former 
injections  frequently  present  the  same  signs,  though  less  pronounced, 
and  the  conjunctiva,  if  the  ophthalmic  tuberculin  test  has  been  given, 
as  well  as  perceptible  tuberculous  foci,  all  show  signs  of  more  or  less 
marked  hj'peremia.  The  recent  work  of  von  Pirquet  ('07),  Wolff-Eis- 
ner ("08),  Calmette  ('07),  and  others  on  the  reactions  occurring  in 
the  skin  and  in  the  e3'e,  following  the  application  of  tuberculin  to  these 
parts,  suggests  that  this  local  reaction  is  definitely  connected  with  the 
tuberculin  and  not  due,  especially  when  great  dilutions  are  used,  to  any 
local  irritation  either  of  the  tuberculin,  of  the  glycerin,  or  of  other 
constituents  or  diluents.  In  many  instances  when  this  local  reaction  is 
disregarded  and  the  usual  rate  of  increase  followed,  the  skin  reaction  be- 
comes more  pronounced  and  finally  is  accompanied  by  a  general  reaction. 

The  relative  irritability  of  the  skin  of  different  areas  has  not  been 
definitely  worked  out,  nor  as  yet  is  this  reaction  satisfactorily  explained, 
though  many  attribute  it  to  increased  susceptibility  (allergie,  anaphy- 
laxis). It  is  inuch  less  pronounced  when  the  injection  is  made  in  the 
back  than  when  given  in  the  limbs.  If  of  great  assistance  in  fore- 
stalling a  general  reaction,  it  would  seem  advisable  to  give  the  tuber- 
culin in  the  forearm,  an  area  of  skin  of  great  sensitiveness,  a  procedure 
which  Spengler  has  long  followed.  Injection  of  tuberculin  in  the  skin 
causes  very  painful  local  redness  and  swelling,  and  at  times  minute 
quantities  of  tuberculin  may  accidentally  be  deposited  in  the  skin  on 
withdrawal  of  the  needle. 

These  "  skin  "  reactions  occur  in  different  individuals  with  different 
intensity  and  vary  at  different  times  in  the  same  individual.  They 
occur  more  frequently  at  first  in  some  patients,  and  in  others  are  never 
present  or  only  with  large  concentrated  doses.  They  are  directly  con- 
nected with  the  form  of  tuberculin  used,  B.  E.  causing  the  reaction  most 
frequently  even  in  great  dilution  (0.00001  mgm.).     In  this  eonnectioii 


DOSAGE  AND  INTERVAL  531 

it  is  of  interest  to  note  that  patients  who  have  received  the  ophthalmo- 
tuberculin  test  and  either  reacted  or  failed  to  react  (solution  used 
1 :  200),  in  some  instances  react  again  more  severely  or  for  the  first  time 
after  the  subcutaneous  injection  of  tuberculin.  This  may  occur  after 
tuberculin  is  used  in  therapeutic  doses  and  is  one  of  the  objections  to 
the  ophthalmo-tuberculin  test. 

Tuberculin  should  always  be  administered  in  the  same  region  of 
the  body  but  on  alternate  sides.  The  concentration  of  the  dose,  on  the 
whole,  seems  to  have  some  influence  on  the  "  skin  "  reaction,  and  a  few 
patients  do  react  in  this  way  to  large  doses  of  concentrated  tuberculin, 
particularly  B.  E.,  but  the  majority  take  1  c.c.  undiluted  of  0.  T.  or 
B.  F.  with  very  slight  reaction.  The  injection  of  tuberculin  into  an 
area  of  induration  produced  by  a  former  injection  is  much  more  likely 
to  cause  this  reaction,  and  in  the  case  of  B.  E.  may  produce  sterile 
abscesses.  Whenever  this  "  skin  "  reaction  occurs  it  is  well  to  repeat  the 
dose  or  to  advance  very  cautiously,  for  in  some  cases  it  is  undoubt- 
edly the  forerunner  of  a  general  reaction.  A  very  severe  "  skin  "  reac- 
tion would  indicate  omission  of  one  or  two  doses  and  the  use  of  smaller 
doses  for  a  time. 

Organ  Reactions. — The  occurrence  of  local  or  "  organ  "  reactions, 
manifested  by  hyperemia,  are  of  great  value  when  they  so  occur  that 
they  can  be  observed  readily  (e.g.,  in  lupus,  laryngitis,  etc.),  but  it  is 
fallacious  to  base  any  method  of  dosage  on  the  "  organ  reaction  "  occur- 
ring in  the  lungs,  for  it  cannot  be  detected  by  our  methods  of  explo- 
ration in  at  least  sixty  per  cent  of  all  tuberculin  reactions  where  severe 
general  reactions  occur,  and,  further,  the  occurrence  of  physical  signs 
in  the  lungs  is  notoriously  uncertain  even  when  tuberculin  is  not  ad- 
ministered. Petruschky  holds  these  organ  reactions  of  importance  for 
cure,  and  Phillipi  lays  considerable  stress  on  the  increase  and  decrease 
of  catarrhal  signs.  The  writer  has  not  used  von  Euck's  watery  extract 
where  such  reactions  are  said  to  occur  so  frequently  as  to  be  of  value 
in  dosing.  Yon  Eberts  has  noted  a  bleaching  in  an  old  lupus  scar 
when  the  correct  dose  (laboratory  method)  was  given. 

Localizing  Symptoms. — The  localizing  or  "organ"  symptoms  may 
be  absent  even  when  rather  acute  general  sj'mptoms  are  present,  and 
rarely  occur  with  carefully  adjusted  doses.  In  pulmonary  tuberculosis 
these  consist  of  oppression  in  the  chest,  increased  cough,  increased  ex- 
pectoration, pleurisy,  and  shortness  of  breath.  In  vesical  tuberculosis 
increased  frequency  of  micturition,  in  laryngeal  tuberculosis,  lupus  and 
tuberculosis  of  the  eye,  increased  congestion  of  the  part  are  the  main 
manifestations  of  this  "  organ "  reaction,  and  are  often  of  the  greatest 
aid  in  determining  the  dosage,  as  in  the  eye  and  bladder,  particularly, 
the  "  organ  "  reaction  is  very  sensitive. 


532  SPECIFIC  TREATMENT 

The  exact  bearing  of  these  symptoms  on  the  dosage  of  tuberculin 
is  not  always  easy  to  determine,  for  in  many  instances  they  do  increase 
or  occur  from  time  to  time  when  tuberculin  is  not  administered.  The 
safest  course  to  pursue  is  to  attribute  any  sudden  marked  increase  to 
tuberculin,  and  to  omit  several  doses,  reducing  also  the  following  dose. 
If  these  symptoms  are  very  slightly  increased  and  the  patient  is  doing 
as  well  as  usual,  the  same  dose  should  be  repeated  several  times.  If, 
however,  these  s3Tiiptoms  become  more  pronounced,  then  it  is  wise  to 
omit  several  doses  and  to  reduce  the  next  dose.  Cough  and  expectora- 
tion are  said  to  be  increased  at  first  during  the  treatment,  but  such  is 
not  the  writer's  experience.  Hemoptysis  rarely  occurs  during  the  tuber- 
culin treatment,  and  is  best  followed  by  the  omission  of  several  doses 
and  a  reduction  of  the  next  dose.  In  over  200  patients  hemoptysis 
occurred  11  times  in  as  many  patients.  In  many  instances  both  cough 
and  expectoration  are  reduced  following  the  injection.  Pleurisy  rarely 
occurs  so  severely  as  to  necessitate  omission  of  many  doses  and  night 
sweats  are  rare. 

General  Symptoms. — The  general  symptoms  are  by  far  the  most 
important  in  estimating  the  dose,  as  they  give  the  first  signs  of  intol- 
erance. Pronounced  symptoms  should  not  be  expected  for  they  indicate 
overdosing,  but  the  occurrence  of  any  of  the  following  symptoms,  how- 
ever slight,  is  of  great  importance  and  indicates  omission,  reduction, 
or  repetition  of  a  dose.  Slight  headache  is  one  of  the  most  frequent 
of  all  symptoms,  while  severe  headache  rarely  occurs.  Even  if  no  other 
symptom  but  slight  headache  is  noticed,  it  is  wise  to  repeat  the  dose, 
and  severe  headache  should  cause  a  cessation  of  the  treatment.  The 
same  is  true  of  malaise.  Pain  in  the  limbs,  joints,  and  back,  faintness, 
giddiness,  insomnia,  fatigue,  rarely  occur  alone  and  often  are  com- 
bined, which  is  also  true  of  indigestion,  nausea,  and  vomiting.  Somno- 
lence, restlessness,  nervousness,  and  stimulation  are  of  rarer  occurrence, 
and  so,  in  one  way,  of  less  importance.  Chilliness  may  occur  without 
a  perceptible  rise  of  temperature.  A  rash  or  fever  blisters,  as  a  rule, 
occur  only  with  a  pronounced  general  reaction.  Enlarged  glands  are 
very  infrequent. 

The  decision  whether  or  not  these  symptoms  may  be  due  to  the 
tuberculin  is  a  matter  of  moment,  and  at  times  of  considerable  dif- 
ficulty. Here,  as  elsewhere,  it  is  always  wise  to  give  the  benefit  of  the 
doubt  to  the  tuberculin  as  the  causative  factor  and  to  act  accordingly. 

The  occurrence  of  two  of  these  symptoms  should  always  indicate 
a  repetition  of  the  dose,  and  one,  if  severe,  means  an  omission  of  one 
or  more  doses  or  a  reduction  of  the  dose. 

Temperature. — Any  of  these  symptoms  may  occur  without  an  appre- 
ciable rise  of  temperature,  and  so  must  be  considered  as  a  much  more 


DOSAGE  AND   INTERVAL  533 

delicate  and  earlier  indication  of  intolerance  than  rise  of  temperature. 
It  seems  probable  that  some  forms  of  tuberculin  are  less  likely  to 
produce  rise  of  temperature,  without  "prodromal"  symptoms,  than 
others.  This  is  especially  true  of  B.  E.,  where  the  patient  may  feel 
wretched  without  any  elevation  of  temperature.  B.  E.  more  often 
produces  a  sudden  rise  of  temperature  when  previously  none  of  these 
symptoms  had  been  noticed.  Elevation  of  temperature  has  long  been 
looked  on  as  the  chief  characteristic  of  intolerance  and  considered  only 
when  the  temperature  reached  100°  F.  or  more,  but  the  al)sence  of 
rise  of  temperature  is  no  sign  of  the  absence  of  reaction,  which  often 
occurs  witliout  rise  of  temperature. 

General  febrile  reactions  coupled  often  with  inflammatory  organ 
reactions  possess  no  curative  action  and  are  dangerous,  especially  when 
severe  or  repeated.  A  complete  course  of  tuberculin  can  be  given  with- 
out febrile  reaction,  but  the  majority  of  patients  react  at  some  time. 
In  a  course  of  B.  F.,  not  more  than  three  or  four  reactions  should  occur 
in  afebrile  patients,  but  in  B.  E.  these  reactions  will  be  more  numerous 
(eight  to  ten).  The  success  of  tul^ercvdin  therapy  depends  mainly  on 
the  accurate  observation  of  slight  departures  from  the  ordinary  course, 
and  a  rise  of  a  few  tenths  of  a  degree  in  temperature  is  always  of 
moment.  It  is  difficult  to  lay  down  any  hard  and  fast  rules,  but  a 
rise  of  one  degree  or  less,  even  a  few  tenths,  above  the  usual  level, 
even  if  only  temporary,  always  means  a  repetition  of  the  dose,  or  if 
accompanied  by  other  symptoms  a  reduction  of  the  dose  (to  one  fourth 
to  one  sixth  of  the  last  dose).  A  greater  rise — e.g.,  from  normal  to 
100°  to  101°  F. — would  mean  the  omission  of  one  or  two  doses,  and 
then  the  indicated  reduction. 

In  no  case  should  tuberculin  be  given  until  the  temperature  has  been 
normal,  or  at  least  at  the  usual  level  for  two  entire  days,  and  if  the 
reaction  is  at  all  severe,  for  one  week.  If,  on  a  repetition  of  the  same 
dose  after  a  slight  reaction,  a  second  reaction  occur,  it  is  always  well  to 
reduce  the  dose  for  fear  of  producing  hypersensitiveness.  A  progressive 
rise,  however  slight,  even  one  or  two  tenths  a  day,  always  indicates 
cessation  of  the  tuberculin  for  a  time;  in  other  words,  never  give  tuber- 
culin with  a  rising  temperature.  This  holds  also  for  febrile  patients, 
and  until  the  temperature  remains  at  the  same  level  for  at  least  five 
or  six  days,  no  tuberculin  should  be  given. 

It  is  at  times  difficult  to  determine  whether  or  not  the  rise  of  tem- 
perature is  due  to  tuberculin.  As  a  rule,  tuberculin  usually  produces 
its  rise  in  aliout  twelve  to  twent3'-four  hours,  occasionally  in  six  or  as 
late  as  forty-eight  hours,  but  these  limits  are  so  rarely  exceeded  that  a 
rise  of  temperature  occurring  either  before  four  or  after  sixty  hours 
can  usually  be  attri1)utc(l  to  some  other  cause. 


534  SPECIFIC  TREATMENT 

The  temperature  caused  by  tuberculin  is  usually  continuous,  but 
may  be  intermittent  and  extend  over  four  or  tive  days.  The  tempera- 
ture may  not  rise  above  the  normal  limits  (99°  F.)  and  yet  the  range 
increase.  This,  if  explainable  in  no  other  way  (e.  g.,  external  tem- 
perature), should  arouse  suspicion.  The  minimujn  (usually  the 
morning)  temperature  is  of  little  value  if  tuberculin  is  given  at 
night. 

Antipyretic  Action. — When  the  elevated  temperature  is  markedly 
reduced  by  tuberculin,  it  is  unwise  to  increase  the  dose  until  this  effect 
be  lost,  but  if  no  effect  is  noticed  the  dose  should  be  increased  slowly, 
even  until,  as  Bandelier  and  Eoepke  also  hold,  a  slight  reaction  occurs. 
Following  this  the  temperature  is  often  lower.  Much  experience  is 
necessary  to  carry  this  out  successfully,  and  longer  intervals  should  be 
employed,  while  the  usual  increases  may  be  maintained. 

Increased  Susceptibility, — There  is  in  many  patients  a  period  of 
increased  susceptibility,  when  the  patient  reacts  on  the  usual  increase 
and  reacts  often  two  or  three  times  to  decreasing  doses.  This  period 
varies  for  each  tuberculin,  being  most  frequent  in  the  hundredths  or 
tenths  of  a  milligram  (solid  substance)  of  B.  E.,  some  tenths  of  a 
milligram  of  0.  T.,  some  hundredths  or  tenths  of  a  milligram  of  B.  F. 
The  smallest  dose  causing  reaction  was  0.00000005  gm.  B.  E.,  0.0001 
c.c.  0.  T.,  and  0.00000003  c.c.  B.  F.  In  patients  who  have  been  sub- 
jected to  the  tuberculin  test  this  increased  susceptibility  occurs  earlier — 
i.  e.,  to  smaller  doses — than  in  others.  Once  past  this  point  without 
reaction,  it  is  much  less  likely  to  occur.  In  patients  with  great  sus- 
ceptibility the  same  dose  should  be  repeated  many  times  and  occasional 
attempts  made  to  increase  it.  This  susceptibility  is  more  frequent  in 
the  febrile,  in  those  with  extensive  lesions,  and  in  those  in  poor  general 
condition. 

Pulse. — ]\Iuch  importance  has  been  attributed  by  some  (Bandelier 
and  Eoepke)  to  the  pulse  range,  but  in  the  writer's  experience  it  is 
a  less  delicate  guide  than  the  other  symptoms  mentioned.  An  increase 
of  pulse-rate  alone,  however,  usually  indicates  caution  and  the  repetition 
or  reduction  of  the  dose. 

Weight. — The  weight  is  of  much  less  importance  in  regard  to  the 
individual  dose  than  in  regard  to  the  treatment  in  general.  A  con- 
tinuous loss  of  weight,  which  proceeds  until  the  normal  weight  for 
height  and  age  is  not  maintained,  or  until  the  individual's  "  normal " 
weight  is  no  longer  held,  means  cessation  of  treatment  until  the  loss 
is  repaired.  The  normal  weight  curve  for  patients  with  tuberculosis 
rises,  as  a  rule,  from  August  to  December,  fluctuates  from  December 
to  March,  and  then  falls  to  August  (Brown,  '03).  This  fact  should 
be  kept  in  mind  in  determining  the  influence  of  the  tuberculin  on  the 


DOSAGE  AND   INTERVAL  535 

weight.  A  loss  of  appetite  means  omission  of  several  doses  and  reduc- 
tion of  the  following  dose. 

From  all  this  it  ma}'  be  seen  that  whenever  any  of  these  SAmiptoms 
or  signs,  however  slight,  arise,  one  of  ses'eral  courses  is  open:  (1)  To 
repeat  the  dose,  (2)  to  lengthen  the  interval,  (3)  to  reduce  the  dose, 
and  (4)  to  omit  the  dose.  Tuberculin  cannot  be  given  on  an  "  express- 
train  "  schedule,  and  the  object  is  not  to  reach  any  definite  station 
where  great  benefilt  will  be  derived,  but  it  is  to  travel  slowly,  stopping 
b}'  each  way  station,  as  long  as  improvement  is  noticed  and  pushing 
on  only  by  slow  degrees.  The  benefit  is  derived  during  the  journey, 
not  at  its  end,  and  just  as  we  cannot  all  climb  to  the  same  altitude,  so 
we  cannot  all  advance  as  far  up  the  tuberculin  scale,  though  we  may 
derive  from  it  the  same  benefit. 

If,  at  any  time  during  the  treatment,  it  becomes  necessary  to  change 
the  "  brew "  of  tuberculin,  even  if  the  new  be  made  from  the  same 
tubercle  bacilli,  the  same  broth,  and  in  exactly  the  same  way,  it  is  wise 
to  reduce  the  next  dose  to  from  forty  to  sixty  per  cent  of  the  last. 

It  is  manifestly  unwise  to  interrupt  any  treatment  that  is  doing 
good,  but  occasionally  it  is  necessary  to  do  so,  and  beside  requiring  a 
reduction  of  the  dose,  the  interruption  has  but  little  effect. 

Complications. — The  occurrence  of  complications — e.  g.,  a  perineal 
abscess,  a  slight  coryza,  acute  bronchitis,  indigestion,  etc. — often  pro- 
duces increased  susceptibility,  and  so  demands  for  a  time  the  cessation 
of  treatment.  The  slightest  departure  from  the  ordinary  course  of 
events  must  be  considered  carefully,  and  it  is  often  wise  to  omit  one  or 
two  doses. 

Age. — The  age  naturally  modifies  somewhat  the  dosage,  and  in  chil- 
dren it  is  wiser  to  begin  with  the  lower  limits  of  the  doses  scheduled. 
Bandelier  and  Eoej)ke  ('08)  believe  the  dose  should  be  one  half  to  one 
tenth  of  that  for  the  adult. 

Estimation  of  Patient's  Condition. — A  patient  may  be  said  to 
be  doing  well  when  his  temperature  and  pulse  remain  normal  or  become 
lower  and  slower  (except  for  one  or  two  days  following  injection), 
when  the  appetite  is  good,  the  weight  increased,  or  the  normal  weight 
maintained,  when  the  general  condition  is  good  and  when  the  pulmonary 
symptoms  are  in  any  wise  decreased.  On  the  other  hand,  if  the  tem- 
perature and  pulse  become  higher  and  faster  for  several  days,  the  gen- 
eral condition  fail,  the  appetite  become  poor,  the  weight  decrease,  and 
pulmonary  symptoms  steadily  increase  or  recur  (hemoptysis,  pleurisy), 
the  condition  of  the  patient  is  unsatisfactory  and  the  treatment  should, 
for  a  time  at  least,  be  discontinued. 

Final  Dose. — The  final  dose  to  be  attained  in  any  course  of  tuber- 
culin dq)ends  on  the  individual,  his  susceptibility  to  tuberculin,  and  the 


536  SPECIFIC  TREATMENT 

variety  used.  No  satisfactory  proof  has  been  adduced  to  show  that 
large  doses  are  of  more  avail  than  smaller  doses,  and  some  patients  who 
can  never  attain  the  larger  doses  seem  to  do  just  as  well  as  those  with 
great  insusceptibility  to  tuberculin.  There  is,  however,  some  connection 
between  tolerance  and  improvement,  for  when  a  patient  relapses  sen- 
sitiveness returns  or  intolerance  may  be  accpiired,  and  Denys  ("05)  holds 
that  large  doses  alone  establish  solid  immunity.  Cornet  believes  that 
larger  doses  do  help  more,  but  are  inadmissible. 

Marked  tuberculin  immunity  can  be  obtained  in  a  majority  of 
patients,  but  it  is  still  an  open  question  whether  immunity  to  large 
doses  should  always  be  attempted.  Sahli  ('OG)  believes  that  tuberculin 
immunity  is  tbe  only  thing  tuljerculin  can  accomplisli.  Trudeau,  Ban- 
delier  and  Eoepke  ('08),  and  others  believe  that  tuberculin  immunity 
is  of  great  value  and  should  be  the  ol)ject  in  the  treatment.  Tuberculin 
immunity  is  not  immunity  to  tuberculosis,  and  animals  immunized  to 
tuberculosis  show  tuberculin  susceptibility  for  some  time.  Petruschky 
has  long  held  that  large  doses  of  tuberculin  are  not  necessary,  that 
tuberculin  immunity  is  the  main  object  to  be  attained,  and  that  re- 
peated courses  of  tuberculin  with  smaller  final  doses  than  usually  rec- 
ommended produce  tlie  best  effect  more  quickly.  Sahli  speaks  of  the 
optimal  dose  for  each  individual  and  pays  little  or  no  attention  to  the 
absolute  dosage,  regarding  only  the  relative  dosage,  and  believing  that 
tuberculin  is  the  best  treatment  to  avoid  dangerous  intoxication. 

These  facts  bring  clearly  before  us  the  objects  of  tuberculin,  and 
while  the  weight  of  opinion  seems  in  favor  of  producing  tuberculin 
immunity  and  so  aiding  the  hody  forces,  b}^  removing  the  toxemia,  to 
overcome  the  tubercle  l)acillus,  the  results  by  this  method  have  never 
been  as  striking  as  those  attained  (especially  in  surgical  tuberculosis) 
by  small  repeated  doses  of  tuberculin,  which,  however,  does  produce 
some  tuberculin  immunity.  Bandelier  and  Eoepke  hold  that  the  best 
final  dose  is  one  that  can  be  borne  without  reaction,  and  may  not  be 
over  1  mgm.  Whether  these  results  rest  on  increased  susceptibility, 
anaphylaxis,  aJlcrgie,  or  some  hitherto  undescribed  immunity  process, 
cannot  yet  be  said,  but  such  results  have  led  the  writer  to  believe  that  the 
increasing  dosage  (to  large  amounts)  in  the  use  of  tuberculin  will  be 
pushed  less  and  less,  but  that  large  doses  may  be  necessary  in  some 
instances. 

Pardee's  ("05)  experience  with  T.  R.  in  tuberculosis  of  the  urinary 
tract  is  a  striking  example  of  this.  He  is  guided  by  the  s5'^mptoms, 
begins  with  0.000002  gm.,  and  increases  until  a  reaction  occurs,  then 
reduces  the  dose  considerably  and  gives  the  same  dose  over  a  long 
period.  His  results  were  excellent  and  seem  to  depend  on  the  great 
irritability  of  the  bladder   (possibly  to  increased  secretion  of  irritants. 


DOSAGE   AND   INTERVAL  537 

followinfj  the  injection,  T.iiieli,  unfortunately,  in  the  case  of  the  luno^s 
is  lacking). 

These  facts  suggest  that  the  anatomy  of  the  part — that  is,  its  rich- 
ness in  vascular  supply — may  have  some  hearing  on  the  method  of 
administration  of  tuberculin.  The  good  results  obtained  by  Wright's 
method  are  practically  all  in  "  surgical "  tuberculosis — that  is,  in  parts 
where  the  blood-vessels  are  usually  less  numerous  and  where  the  walls 
may  be  less  permeable.  Pronounced  pulmonary  tuberculosis,  he  states, 
is  not  suitable  for  this  line  of  treatment  on  account  of  the  frequent 
autoinoculations  that  occur.  When  the  opsonic  index  is  totally  dis- 
regarded in  this  form  of  tuberculosis  and  tuberculin  immunity  is 
attempted,  good  results  are,  to  say  the  least,  not  infrequent. 

Arbitrary  limits  have  been  set  for  many  forms  of  tuberculin  (1  c.c. 
for  0.  T.,  B.  F.,  and  Beraneck's,  5  mgm.  solid  substance  for  B.  E.,  20 
mgm.  for  T.  E.,  etc.),  but  why  these  doses  in  some  instances  should 
not  be  surpassed  has  been  little  discussed.  Den}^?  has  given  up  to 
10  c.c.  of  B.  F.  subcutaneously  and  2.5  c.c.  intravenously,  and  Koch 
recommended  10  mgm.  B.  E.  subcutaneously  or  a  larger  dose  (20 
mgm. )  intravenously. 

It  is,  however,  a  much  wiser  procedure  to  limit  the  final  dose  by 
the  time  required  for  the  tuberculin  treatment.  A  dose  that  falls  short 
of  the  usual  final  dose,  that  has  required  nine  to  twelve  months  to  attain, 
should,  merely  on  account  of  the  time,  be  looked  on  as  the  final  dose, 
no  matter  how  small.  On  the  other  hand,  it  is  rarely  wise  to  exceed 
the  following  doses :  0.  T.,  1  c.c. ;  B.  F.,  1  to  3  c.c. ;  B.  E.,  5  mgm. ; 
T.  E.,  10  to  20  mgm.;  Beraneck's,  1  c.c.  The  final  dose  of  B.  E. 
should  always  be  diluted  and  given  in  two  places.  Thorner  holds  that 
0.001  c.c.  0.  T.  should  never  be  exceeded  in  febrile  patients.  One 
patient  who  had  showed  remarkably  little  susceptibility  to  B.  F.  acquired 
hypersusceptibility  when  the  dose  was  increased  from  1  c.c.  to  1.2  c.c. 
and  reacted  to  the  ophthalmo-tuberculin  test. 

In  a  number  of  patients  the  writer  could  never  increase  the  dose 
beyond  a  few  milligrams  of  old  tul)erculin,  some  thousandths  of  a  milli- 
gram of  B.  F.,  and  some  hundredths  of  a  milligram  of  B.  E.  (solid 
substance).  For  the  most  part  (nine  out  of  eleven)  they  had  extensive 
lesions,  one  had  an  enlarged  thyroid  with  some  exophthalmos  and  a 
second  developed  a  perineal  abscess. 

Many  authorities  advocate  the  repetition  of  the  final  dose  a  number 
of  times,  as  long  as  it  does  good,  with  the  view  of  increasing  the  immu- 
nity. Denys  ('05)  finds,  however,  that  a  stage  of  intolerance  is  at 
times  acquired  in  this  way,  and  the  writer  has  seen  several  instances 
of  it.  In  this  case  the  dose  must  be  reduced  or  the  treatment  discon- 
tinued.   On  the  whole,  when  sufficient  time  has  elapsed  since  the  begin- 


538  SPECIFIC  TREATMENT 

ning  of  treatment,  it  is  wise  to  discontinue  the  treatment  for  a  time 
when  the  foregoing  limits  are  reached.  If,  however,  the  patient  feels 
a  lack  of  the  stimulation  produced  by  the  tuberculin,  it  may  speedily 
be  begun  anew. 

Hypersusceptibility. — No  schematic  plan  of  dosage  can  be  blindly 
followed,  as  individualization  plays  the  most  important  part  in  treat- 
ment with  tuberculin.  The  proper  rate  of  increase  varies  for  each 
individual,  and  also  for  the  same  patient  at  different  times  during  the 
treatment.  The  smaller  doses  are  often  given  with  larger  increases, 
and  some  have  noted  a  period  of  increased  susceptibility  which  varies 
for  each  tuberculin.  During  this  period  greater  care  should  be  exer- 
cised, for  the  condition  of  hypersusceptibility  may  be  more  readily 
produced  at  this  time.  This  condition  must  be  carefully  guarded 
against,  as  it  frequently  occurs  from  overdosage  or  from  giving  tuber- 
culin during  a  period  of  a  slight  exacerbation,  too  soon  after  a  reac- 
tion, or  during  decreased  resistance  (slight  coryza,  gastric  or  intestinal 
disturbance,  etc. ) . 

It  is  manifested  at  times  by  a  more  or  less  sharp  reaction  which 
necessitates  a  marked  reduction  of  the  next  dose.  This,  however,  also 
produces  a  reaction,  which  may  follow  several  doses,  each  much  reduced 
in  turn.  The  only  plan  if  this  occurs  is  to  discontinue  the  tuberculin 
for  several  weeks,  or  even  months,  and  then  begin  again  very  slowly. 
In  one  patient,  a  woman,  this  hypersusceptibility  was  produced  by 
the  injection  of  0.0000001  c.c.  B.  F.  as  a  first  dose  several  days  after 
a  slight  attack  of  pleurisy.  In  four  months  of  treatment  this  dose  was 
never  again  attained,  and  the  treatment  had  to  be  stopped  on  account 
of  the  severe  headaches  it  produced. 

The  "  quotient  of  immunization "  of  Loewenstein  and  Rappoport 
(i.  e.,  relation  of  the  maximum  dose  injected  Avithout  reaction  and  the 
number  of  doses  necessary  to  arrive  at  this  dose)  is  much  greater  for 
early  than  advanced  stages. 

Value  of  Small  Doses. — The  interesting  problem  of  increased  sus- 
ceptibility to  serums  (von  Pirquet  and  Schick  ('05),  Eosenau  and  An- 
derson ('08))  suggests  that  a  tuberculin  anaphylaxis  is  possible,  though 
the  small  interval  between  doses  seems  to  render  it  improbable.  Fol- 
lowing the  tuberculin  test,  hypersusceptibility  is  often  present  in  a 
marked  degree,  and  Loewenstein  has  found  it  to  persist  for  many 
months.  It  is  not  impossible  that  the  increase  in  dosage,  especially  at 
first,  is  so  small  for  some  little  while  that  the  mechanism  of  the  body 
is  not  adjusted  finely  enough  to  appreciate  the  increase,  and  so,  when 
very  minute  doses  are  used,  a  hypersusceptibility  may  be  produced  when 
the  organism  is  at  all  susceptible. 

Loewenstein  and  Eappoport   ('04)   have  shown  this  to  be  true  for 


DOSAGE  AND   INTERVAL  539 

larger  doses  of  0.  T.  (0.0002  c.c.)  repeated  several  times,  and  Koch 
has  pointed  out  that  this  phenomenon  is  very  characteristic  of  tuber- 
culin. This  may  be  the  explanation  of  some  reactions  to  very  small 
doses,  and  may  further  explain  the  good  results  obtained  with  small 
repeated  doses  of  T.  R.  (^Yright  and  others).  It  is  of  interest  to  note 
that,  in  a  woman  aged  twenty-four,  with  closed  infiltration  of  the  right 
upper  lobe,  while  0.0001  mgm.  T.  E.  repeated  weekly  never  brought 
the  opsonic  index  to  normal,  it  apparently  produced  immunity  to  0.  T. 
(0.01  c.c.  0.  T.  subcutaneously)  and  to  the  ophthalrao-tuberculin  test 
(1  to  200). 

Schemata. — Some  advocate  the  continued  use  of  small  doses,  which 
seems  especially  of  value  in  surgical  tuberculosis,  depending,  however, 
largely  on  the  clinical  symptoms  for  guidance.  The  majority  advise 
tuberculin  to  be  given  in  increasing  doses,  and  many  schemata  have 
been  suggested.  The  fundamental  principles  have  not  yet  been  fully 
settled,  and  whether  it  is  wiser  to  increase  irregularly  or  by  a  definite 
logarithmic  scale  cannot  at  present  be  definitely  answered.  The  major- 
ity use  an  irregular  scale,  1,  2,  3,  4,  5,  6,  7,  8,  9,  10,  20,  30,  etc.,  Avith 
increases  that  vary  from  a  hundred  per  cent  down  to  eleven  per  cent. 
The  experience  of  the  writer  seems  to  indicate  that  reactions  occur 
most  frequently  when  passing  from  1  to  2  or  from  2  to  3  of  this  scale. 
Accordingly,  for  some  time  the  following  scale  was  used  at  the  Adi- 
rondack Cottage  Sanitarium:  1,  1.5,  2,  2.5,  3,  4,  5,  6,  8,  10,  15,  etc., 
with  increases  varying  frequently  from  fifty  to  twenty  per  cent.  This 
seemed  to  prevent  reactions  at  the  points  indicated.  Bandelier  and 
Eoepke  ('08)  use  the  following  doses:  1,  1.5,  2,  3,  5,  7,  10,  while 
Petruschky  employs  (in  milligrams)  0.1,  0.25,  0.5,  1,  2,  3,  4,  6,  8,  10, 
15,  25,  35,  45,  60,  80,  100,  etc. 

Logarithmic  Scale. — More  recently  still,  Weber's  law  of  sense- 
perception  has  been  taken  cognizance  of,  and  a  logarithmic  scale  has 
been  constructed. 

Concentration  and  Dosage. — Inasmuch  as  the  effect  of  the  varia- 
tion in  concentrations  used  has  seemed  to  the  writer  to  exert  no  influ- 
ence, Sahli's  suggestion  of  having  each  higher  dilution  only  twice 
instead  of  ten  times  the  strength  of  the  preceding,  which  is  the  usual 
method,  seems  entirely  unnecessary,  and  requires  much  time  (e.  g.,  for 
B.  F.  at  least  fifteen  months  for  one  course).  Reaction  on  going  from 
0.68  c.c.  of  one  solution  to  0.1  c.c.  of  one  ten  times  as  strong  has 
caused  no  reaction  in  a  large  number  of  cases.  The  advantage  of  hav- 
ing each  solution  ten  times  the  strength  of  the  preceding  one  is  mani- 
fest. Sahli  gives  from  0.1  to  0.5  c.c.  of  one  solution,  and  then  changing 
to  one  twice  as  strong  repeats  the  same  dose  once,  giving  consequently 
0.25  c.c,  and  so  on.     There  is  no  evidence  to  show  that  this  is  neces- 


540 


SPECIFIC  TREATMENT 


sary.  Denys  uses  a  solution  ten  times  stronger  than  the  preceding,  and 
advances  usually  from  1,  2,  3,  4,  5,  6,  7,  8,  9,  to  0.1  of  the  next  solution. 
At  times  he  advances  by  0.1,  0.25,  0.5,  0.75,  1,  and  so  on. 

It  is  intended  merely  as  a  suggestion  in  controlling  the  dosage, 
which  for  each  patient  varies  greatly,  according  to  individual  suscep- 
tibility, and  is  of  use  in  giving  any  tuberculin,  for  all  tuberculins  are 
either  in  solution  or  suspensions  in  fluids.  This  schema,  computed  by 
Pope,^  is  based  on  a  logarithmic  scale,  and  is  so  arranged  that  in  going 
from  0.1  to  1  c.c.  of  any  solution  two  to  twelve  doses  may  be  employed, 
while  the  rate  of  increase  of  dose  in  each  case  is  always  constant.  The 
average  patient,  in  the  writer's  experience,  can  take  the  sixth  scale 
(six  doses  to  each  solution)  without  any  danger  of  reaction,  but  some 
must  go  more  slowly,  and  a  few,  especially  during  a  second  course,  may 
go  more  rapidly. 

DOSES   (LOGARITHMIC   SCALE) 


2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

1 

3.2 

2.2 

1.8 

1.6 

1.5 

1.4 

1.3 

1.3 

1.3 

1.2 

1.2 

10 

4.7 

3.2 

2.5 

2.2 

2.0 

1.8 

1.7 

1.6 

1.5 

15 

10 

5.6 

4.0 

3.2 

2.7 

2.4 

2.2 

2.0 

1.8 

1.8 

10 

6.3 

4.7 

3.7 

3.2 

2.8 

2.5 

2.3 

2.2 

10 

6.8 

5.2 

4.2 

3.6 

3.2 

2.9 

2.6 

10 

7.2 

5.6 

4.7 

4.0 

3.5 

3.2 

10 

7.5 
10 

6.0 

7.7 
10 

5.0 
6.3 
8.0 
10 

4.3 
5.3 
6.6 
8.0 
10 

3.8 
4.7 
5.6 
6.8 
8.3 
10 

1.  Bouillon   filtrate.      Interval:   twice   a   week   until   0.1    c.c,    then 

once    a    week.      Doses    (in    cubic    centimeters)  :    beginning, 
afebrile,  0.0000001-5 ;  febrile,  0.00000001-2 ;  final,  1  c.c. 

2.  Original    tuberculin     (Koch's).       Doses    in    cubic    centimeters. 

Interval:  twice  a  week,  after  0.1  c.c.  may  be  given  once  a 
week.     Beginning  dose  same  as  B.  F.,  final,  1  c.c. 

3.  Bacillen  emulsion : 

a.  Doses  in  solid  substance  (grams).  Interval;  twice  a  week 
until  .001,  then  once  a  week.  Beginning  dose  afebrile, 
0.0000001 ;  febrile,  0.00000001 ;  final  dose,  .005. 


iThe  writer  takes  this  opportunity  of  acknowledging  the  great  assistance  he  has 
received  in  many  parts  of  this  article  from  the  late  Mr.  E.  G.  Pope,  statistician  of 
the  Adirondack  Cottage  Sanitarium. 


SELECTION   OF   PATIENTS  541 

6.  Doses    in    liquid    measure    (cubic    centimeters).      Interval: 
twice  a  week  until  0.2  c.c,  then  once  a  week.     Beginning 
dose   afebrile,   0.00001    c.c;   febrile,   0.000001    c.c;   final 
dose,  1  c.c. 
Tuberculin  R. : 

a.  Doses  in  solid  substance   (grams).     Interval:  twice  a  week 

until  .005,  then  once  a  week  or  less  frequently.  Begin- 
ning dose  afebrile,  0.0000001;  febrile,  0.00000001;  final 
dose,  0.01  to  0.02.  Dosage  after  0.01:0.012,  0.015, 
0.01  r,   0.03. 

b.  Doses   in    liquid    measure    (cul)ic    centimeters).      Interval: 

twice  a  week  until  0.02  c.c,  then  once  a  week  or  less  fre- 
quently. Beginning  dose  afebrile,  0.00001  c.c ;  febrile, 
0.000001  c.c. ;  final  dose,  1  to  2  c.c.  Dosage  after  1  c.c. : 
1.2,  1.5,  1.7,  2  c.c 
Beraneck's.  Doses  in  cubic  centimeters.  Interval :  twice  a  week. 
Beginning  dose  afebrile,    0.05   c.c.   of    ^   solution;   febrile, 

final     rlriGP      1      i 
128  ' 

tuberculin). 


0.05  c.c.  of    A    or   r^  ;  final  dose,  1   c.c   of  T.   Bk    (pure 


SELECTION    OF    PATIENTS 

Theory  of  Action. — The  theory  of  action  of  tuberculin  has  much 
bearing  on  the  selection  of  patients.  Formerly,  when  Koch  held  that 
tuberculin  caused  a  sloughing  off  of  the  tuberculous  areas,  all  patients 
except  those  in  early  stages  were  soon  considered  from  this  standpoint 
as  unsuital)lo,  many  of  whom  now  are  subjected  to  the  treatment.  On 
the  other  hand,  the  acuteness  of  the  process,  formerly  disregarded,  now 
plays  an  important  ])art.  Tuberculin  is  not  an  antitoxin,  but  a  toxin, 
and  the  process  of  "tuberculin  immunization"  is  not  passive  but  active. 
The  majority  of  observers  (Trudeau  and  Baldwin,  etc.)  have  failed 
to  find  any  antitoxin  in  the  serum,  either  during  tuberculosis  or  during 
tuberculin  treatment.  The  struggle  seems  closely  connected  with  the 
cells,  probably  those  about  the  foci,  and  some  observers  (Wasserman 
and  Bruck)  have  noted  an  antituberculin  in  the  tissues. 

An  incubation  period  of  six  to  twelve  hours  intervenes  after  the 
injection  of  tuberculin  before  a  rise  of  temperature  occurs.  What 
occurs  during  this  period  of  absorption  and  "  attuning  "  of  the  system 
is  impossible  to  say,  but  it  may  be  that  tuberculin  acts  as  an  "  enzy- 
mogen,"  which  in  time  sets  free  from  the  cells  about  the  tubercle  suf- 
ficient toxin  of  digested  tubercle  bacilli  to  produce  the  reaction.  By 
this  theory  it  is  easy  to  understand  how  tuberculin  would  prove  only 
of  injury  to  acute  cases  already  overwhelmed  by  toxin.     It  is  also  easy 


542  SPECIFIC  TREATMENT 

to  see  how  overdosage,  by  liberating  too  much  toxin,  may  overwhelm 
the  organism,  interfere  with  nutrition,  and  so  produce  disastrous  results. 
The  gradual  liberation  of  the  toxins  of  the  digested  tubercle  bacilli, 
brought  about  by  small  doses  of  tuberculin,  may  free  many  already 
overloaded  cells  about  the  focus,  thus  enabling  and  stimulating  them 
to  attack  and  digest  any  bacilli  escaping  from  the  lesion,  and  permitting 
and  stimulating  the  connective-tissue  cells  to  act  more  rapidly  in  form- 
ing a  capsule  about  the  focus. 

In  the  ordinary  course  of  the  disease,  according  to  another  theory, 
the  tuberculin  is  formed  so  gradually  that  the  whole  organism  is  rarely 
stimulated  to  the  formation  of  any  antibodies;  in  the  tuberculin  treat- 
ment a  large  amount  is  thrown  into  the  circulation  at  once,  and  so  the 
whole  system  is  immunized  in  some  way  against  tuberculin.  This  may 
permit  the  bacteriolytic  properties  of  the  tissues  to  exert  themselves, 
whereas  before  they  were  too  weakened  to  do  so;  in  other  words,  it 
permits  an  auto-immunization  to  take  place. 

The  explanation  of  the  failure  of  many  patients  in  far-advanced 
stages  to  react  to  tuberculin  may  be  that  a  system,  already  saturated 
with  toxin,  reacts  less  readily,  if  at  all,  to  an  increase  of  the  toxin, 
and  in  these  cases  the  cells  are  so  affected  that  they  can  no  longer 
respond  to  stimulation.  They  can,  as  Mitulescu  says,  neither  take  in 
material  necessary  for  reconstruction  nor  protect  themselves  against 
the  action  of  poisonous  substances.  Tuberculin,  Sahli  believes,  is  not 
merely  a  specific,  but,  like  digitalis  in  cardiac  disease,  a  functional 
therapeutic  means  which  acts  only  in  a  definite  way  on  the  toxin  sus- 
ceptibility of  the  organism.  The  natural  healing  powers  are  permitted 
to  act  after  tuberculin  has  combated  tlie  toxemia. 

It  is  of  interest  to  recall,  as  Loewenstein  has  pointed  out,  that 
almost  all  diseases  in  which  immunization  takes  place  are  acute  diseases. 
The  struggle  is  sharp  and  quickly  decisive,  ending  before  the  cells  lose 
their  powers  of  resistance  (antitoxin  formation).  Tuberculosis  is  a 
chronic  disease  whose  pathogenicity  depends  ratlier  on  the  ability  of  the 
tubercle  bacillns  to  live  and  multiply  in  the  tissues,  than  on  the  potency 
of  the  poisons  they  produce  (Vaughan).  The  nutrition  is  profoundly 
affected  by  this  poison  or  toxin,  a  fact  which  gives  the  pulmonary  form 
its  vulgar  name — consumption.  Tlie  toxemia  usually  progresses  so 
slowly  that  its  advance  can  scarcely  be  noted  from  day  to  day.  Small 
quantities  of  the  toxin  of  the  tubercle  bacillus  affect  man  profoundly, 
while  he  has  usually  fairly  good  resisting  powers  against  the  tubercle 
bacillus  itself.  Such  facts  would  suggest  that  could  immunity  to  tuber- 
culous toxin  be  produced,  man  in  many  instances  could  overcome  the 
tubercle  bacillus.  However  this  may  be,  remarkable  tuberculin  immu- 
nity  may   be   acquired   and  maintained    for   long  periods   by    suitable 


SELECTION   OF   PATIENTS  543 

repetitions  of  the  treatment.  (See  Eepeated  Courses.)  Immunity 
to  tuberculin,  unfortunately,  does  not  mean  immunity  to  tuberculosis, 
as  many  experiments  have  shown,  and,  on  the  other  hand,  susceptibility 
to  tuberciriin  does  not  always  mean  lessened  resistance  to  a  previously 
acquired  tuberculosis.  The  results  obtained  in  patients  with  surgical 
tuberculosis  immunized  to  tuberculin  are  rarely,  if  ever,  so  striking  as 
many  instances  reported  of  patients  treated  by  Wright's  method,  but 
many  have  been  unable  to  substantiate  these  results. 

Symptoms  and  General  Condition. — From  this  Ave  may  conclude  that 
all  patients  with  acute  tuberculosis,  all  patients  whose  nutrition  is  so 
profoundly  affected  that  little  response  is  possible,  are  unsuited  for 
tuberculin  treatment.  When  the  general  condition  is  far  below  normal 
every  effort  should  be  made  to  improve  it,  and  at  the  same  time  to 
reduce  the  temperature  and  to  abate  the  sjTuptoms,  before  resorting  to 
the  use  of  tuberculin,  but  Bandelier  and  Roepke  believe  that  if  the  time 
is  short  (e.  g.,  on  account  of  financial  resources)  tuberculin  should  be 
begun  at  once  and  nothing  else  omitted  to  improve  the  condition  of 
the  patient.  The  results  in  such  patients  are,  of  course,  as  Petruschky 
('04)  points  out,  much  more  uncertain  than  in  those  in  incipient  stages. 

Elevated  Temperatures. — Most  observers  select  only  those  patients 
whose  symptoms  indicate  an  arrest,  possibly  only  temporary,  of  the 
disease.  For  this  reason,  elevated  temperature  is  said  to  be  a  contra- 
indication to  the  use  of  tuberculin,  but  recent  experience  shows  that 
this  is  not  true  for  all  patients  with  elevated  temperature.  Many 
patients  who  persistently  have  a  slightly  elevated  temperature  ranging 
from  normal  or  below  to  99.5  to  100°  F.,  presenting  at  the  same  time 
no  other  very  marked  symptoms,  do  remarkably  well  with  tuberculin, 
and  often  regain  a  normal  temperature.  If,  on  the  other  hand,  the  tem- 
perature be  persistently  high,  rarely  falling  below  100°  F.  for  a  period 
of  some  weeks,  tuberculin  can  accomplish  little.  On  the  whole,  it  is 
rarely  a  wise  procedure  to  give  tuberculin  to  any  patient  whose  tem- 
perature reaches  101°  F.  or  over  unless  all  other  symptoms  are  dis- 
tinctly favorable,  and  too  much  must  not  be  expected  in  any  case. 
Koch,  Goetsch,  Holdheim,  etc.,  oppose  the  use  of  tuberculin  in  patients 
with  fever. 

A  persistently  rapid  pulse  after  prolonged  rest  is  a  contraindication 
in  most  cases  to  tuberculin.  Such  patients  do  badly,  and  while  not 
harmed,  frequently  derive  little  benefit  from  tuberculin.  Cough  or 
expectoration  in  themselves,  unless  excessive,  are  of  small  importance 
in  connection  with  the  selection  of  patients,  but,  when  excessive,  great 
caution  should  be  used  if  tuberculin  be  administered  at  all.  Slight 
dyspnea  is  of  little  moment,  urgent  dyspnea  is  a  contraindication.  A 
tendency  to  hemoptysis  is  no  contraindication,  and  dry  pleurisy,  existing 


544  SPECIFIC  TREATMENT 

for  some  time,  is  of  no  significance  unless  very  painful,  and  if  not 
increased  by  tuberculin,  need  be  little  considered.  Pleurisy  with  effu- 
sion after  the  acute  stages  are  over  need  not  cause  any  interference  with 
the  treatment.  A  feeling  of  oppression  in  the  chest,  unless  arising  dur- 
ing the  treatment,  is  no  contraindication.  Emaciation  and  anorexia  are, 
as  previously  stated,  contraindications. 

Complications. — Most  complications  have  with  many  men  little 
influence  on  the  selection  of  patients,  but  the  prognosis,  which  is  always 
worse  in  such  cases,  should  always  be  considered.  Meningitis  is  an  abso- 
lute contraindication,  but  Vernet  ('07)  has  stated  that  he  cured  one 
case  in  a  child,  and  Maurange  ('9G)  noted  marked  improvement  in 
another.  The  occurrence  of  a  true  nephritis  (not  the  presence  of  a 
few  casts  in  centrifugalized  urine  or  the  slightest  trace  of  allnnnin)  is 
a  contraindication  in  most  cases.  This  does  not  hold  for  tuberculous 
nephritis,  where  many  good  results  have  been  obtained  (von  Euck, 
Whipple,  and  Duriac).  Diabetes  and  cirrhosis  of  the  liver  are  absolute 
contraindications  for  many  who  state  no  reason  but  a  bad  prognosis. 
Marked  nervous  symptoms,  hysteria,  neurasthenia,  exophthalmic  goiter, 
considered  by  some  as  contraindications,  necessitate  care,  but  many  of 
these  patients  seem  to  derive  from  tuberculin  the  mental  leverage  neces- 
sary to  carry  them  over  rough  places,  as  it  enables  them  to  attribute 
to  tuberculin  many  slight  exacerbations  which  otherwise  would  cause 
great  mental  disturbance.     This  is  a  factor  of  no  little  importance. 

Epilepsy,  if  not  a  positive  contraindication,  would  necessitate  the 
greatest  care.  Syphilis  is  no  contraindication  (Heron,  Thorner).  Valv- 
ular disease  of  the  heart,  if  any  history  of  noncompensation  be  obtain- 
able, or  if  degeneration  of  the  heart  muscle  or  blood-vessels  occur,  is 
a  contraindication.  The  occurrence  of  secondary  infections,  which 
markedly  influence  the  general  condition  of  the  patient,  is  a  contra- 
indication. Sahli  believes  that  "  mixed  infection  "  is  the  scapegoat  for 
poor  results,  while  Koch  opposes  the  use  of  tuberculin  when  there  are 
"  morbid  processes  "  caused  by  streptococci,  staphylococci,  pneumococci, 
influenza  bacilli,  etc.  The  poisons  of  the  tubercle  bacillus  would  seem 
from  von  Korczynski's  ('05)  work  to  increase  the  virulence  in  vitro 
of  some  organisms  (colon,  streptococcus,  staphylococcus).  Pregnancy 
is  no  contraindication,  and  Petruschky,  basing  his  opinion  on  11  cases, 
10  alive  and  well  and  one  dead  from  pneumonia  with  healed  tuber- 
culosis, holds  that  patients  who  have  been  treated  with  tuberculin  can 
marry  without  risk.  Roepke  strongly  advises  the  use  of  tuberculin  in 
these  cases. 

Physical  Signs. — The  physical  signs,  except  when  extensive  soften- 
ing and  ulceration  have  occurred,  need  little  consideration.  If  such  be 
the  case,  little  can  be  hoped  from  tuberculin  treatment,  and  a  wiser 


SELECTION  OF  TUBERCULIN  545 

course  is  to  refrain  from  its  use,  though  if  such  a  patient  insist  it  should 
be  given.  Patients  whose  extent  of  physical  signs  corresponds  to  stage 
III  Turban,  may  go  through  the  entire  course  withou't  the  slightest 
reaction.  When  the  physical  signs  are  extensive  the  general  condition 
must  be  good  and  the  symptoms  slight,  or  tuberculin  is  contraindicated. 
The  location  of  the  physical  signs  is  of  little  importance. 

Duration  of  Disease. — The  duration  of  the  disease  is  often  an  indi- 
cation for  tuberculin.  The  patient  has  tried  the  hygienic-dietetic  treat- 
ment, a  change  of  climate,  and  what  not,  without  permanent  benefit 
or  even  marked  improvement.  The  disease  has  remained  stationary  or 
possibly  advanced  slightly  at  infrequent  intervals.  Such  patients  are 
preeminently  suited  for  tuberculin,  which  should  always  be  exhibited 
to  them.  The  argument  that  tuberculin  should  be  reserved  only  for 
such  patients  as  fail  to  improve  under  other  forms  of  treatment  is  an 
acknowledgment  of  lack  of  faith  in  tuberculin,  and  if  tuberculin  be  of 
value  for  these  patients  it  is  of  much  more  value  for  patients  in  incip- 
ient stages.  It  is  true,  as  Spengler  states,  that  in  the  incipient  stages 
it  is  impossible  to  determine  what  value  tuberculin  possesses,  but  he 
believes  that  in  more  advanced  stages  his  results  leave  no  doubt  as  to 
the  great  value  of  tuberculin.  A  few  patients,  even  in  the  earliest 
stage,  cannot  take  tuberculin  except  in  the  most  minute  doses,  but  these, 
as  Sahli  says,  are  not  always  the  most  unfavorable. 

Age. — The  question  of  age  in  the  selection  of  patients  need  be  little 
considered  in  its  lower  limits,  as  children  often  do  remarkably  well 
(Petruschky),  though  Vaquier  and  Ganghofner  obtained  only  "fair" 
results.  In  patients  past  fifty  years  especial  attention  should  be  paid 
to  complications  in  the  cardiac  or  renal  systems. 

Prophylactic  Use. — Members  of  phthisical  families,  even  though 
they  present  no  signs  or  symptoms  of  disease,  are  often  benefited  by 
tuberculin  (Sahli).  Patients  who  must  continue  work  should  not  for 
this  reason  alone  be  refused  tuberculin. 

Advice  for  Inquiring  Patients. — The  advice  to  be  given  a  patient 
who  inquires  about  tuberculin  is  of  considerable  moment.  He  should 
be  told  that  tuberculin  properly  given  will  not  harm  him,  may  produce 
no  immediate  results,  but  may  act  very  beneficially  both  in  regard  to 
the  future  (relapse)  and  on  the  symptoms.  It  should  be  clearly  stated 
to  him  that  treatment  for  two  or  three  months  is  of  little  avail,  and 
that  it  means  six  to  nine  months  at  first,  and  later  a  repetition  of  the 
treatment. 

SELECTION    OF    TUBERCULIN 

The  selection  of  a  tuberculin  is  most  difficult.     The  only  perfect 

immunity  obtained  in  animals  has  been  by  use  of  the  attenuated  cul- 
36 


546  SPECIFIC  TREATMENT 

tures  of  the  living  human  tubercle  bacillus,  which  would  suggest  that 
the  tubercle  bacilli  under  stimulation  of  the  cells  and  juices  of  the 
body  produce  some  toxin  not  otherwise  generated  (Welch).  The  results 
have  been  especially  favorable  in  cattle,  which  has  led  several  observers 
to  the  use  of  tuberculin  from  the  bovine  strain  of  tubercle  bacilli,  or, 
indeed,  to  the  use  of  the  bovine  tubercle  l)acillus  itself  (Spongier,  '05). 
Klemperer  ('05)  injected  himself  and  five  patients  without  apparent 
harm  with  a  virulent  bovine  tubercle  bacillus,  but  obtained  no  striking 
results.  Moeller,  after  immunizing  himself  witli  tubercle  bacilli,  passed 
through  a  blindworm,  inoculated  himself  without  effect  with  an  attenu- 
ated tubercle  bacillus  which  apparently  failed  to  kill  guinea  pigs.  His 
experiment  proved  little.  Friedman  carried  out  the  same  experiment 
in  animals,  using  a  turtle  tiibercle  bacillus,  which  was  later  found  to 
be  virulent  in  some  cases. 

In  tuberculosis  in  man  the  tubercle  bacillus  is  already  in  the  body, 
and  it  may  be  questioned  whether  the  inoculation  of  more  tul)ercle 
bacilli  would  prove  of  as  great  value  as  some  hold.  The  normal  and 
tuberculous  animals  react  very  differently  to  the  tuberculous  toxin,  and 
the  use  of  living  tubercle  bacilli  in  tuberculous  cattle  has  not  shown 
striking  results.  In  any  case  it  is  not  justifiable  to  subject  man  to  such 
procedures. 

The  use  of  homologous  tuberculin  or  vaccines  in  tuberculosis  has  met 
with  little  favor,  and  the  best  immunizing  results  have  been  obtained 
with  heterologous  bacteria  (attenuated  human  strains  against  virulent 
bovine  strains).  Loewenstein  and  Allen  believe  that  homologous  tuber- 
culin or  vaccines  should  be  used^  and  Haentjens-Putten  and  Krause 
('07)  have  employed  them,  while  von  Eljerts  believes  they  are  imprac- 
ticable in  skin  lesions.  C.  Spengler  has  claimed  astounding  results  by 
the  use  of  allotoxins;  when  the  infection  is  with  human  tubercle  bacilli, 
as  is  usual,  he  uses  l)ovine  tuberculin  and  vice  versa,  and  when  a  dose 
of  100  mgm.  is  reached,  he  alternates  human  and  bovine  tuberculins  and 
reports  agglutination  in  strength  of  1 : 2,000.  AVoll)ack  and  Ernst 
found  no  difference  experimentally  in  the  action  of  human  and  bovine 
tuberculins. 

Theoretically  it  would  seem  sufficient  to  immunize  man  against  the 
toxin  (tuberculin)  of  the  tubercle  bacillus,  for  as  yet  no  perfect  bac- 
terial immunity  has  been  produced  by  any  other  agent  than  the  living 
bacillus,  and  by  doing  this  enable  him  to  overcome  the  tubercle  bacillus 
itself  against  which  he  has  considerable  resistance.  The  use  of  non- 
toxic split  products  of  the  tubercle  bacillus  of  Vaughan  and  of  the 
nastin  of  Deycke  and  Reschad  Bey,  possibly  also  of  von  Behring's 
tulaselaktin,  are  all  attempts  not  yet  proved  successful  at  bacteriolytic 
action. 


SELECTION   OF  TUBERCULIN  547 

Judging  from  the  results  ol)tained  up  to  the  present  time  there  is 
apparently  little  difference  hetween  the  action  of  the  various  tuber- 
culins when  jiroperly  given,  as  all  probably  contain  the  specific  tuber- 
stance.  The  original  tuberculin  has  in  the  hands  of  many  observers 
given  just  as  reliable  and  satisfactory  results  as  any  of  the  later  modi- 
fications. No  satisfactory  proof  has  been  adduced  to  show  that  the 
culture  fluid  contains  any  substance  not  in  or  a])Out  the  body  of  the 
tubercle  bacillus.  In  fresh  cultures  tubercle  bacilli  rarely  lie  imme- 
diately side  by  side,  but  are  separated  by  some  substance,  which,  dissolved 
in  NH^C'l,  is  capable  of  producing  the  tuberculin  reaction  (Bald- 
win). Schmoeller  ('05),  quoting  Denys,  Koch,  and  Klebs  as  his  authori- 
ties, states  that  the  specifically  acting  substances  are  set  free  in  the 
culture  fluid,  while  the  insoluble  substances  retained  in  the  bacterial 
bodies  have  only  inflammatory  and  pyogenic  properties.  Analogy  with 
other  bacterial  vaccines  would  lead  us  to  believe  that  heat  may  destroy, 
in  part  at  least,  the  immunizing  substance,  and  it  certainly  produces  a 
precipitate.  For  these  reasons  it  would  seem  best,  theoretically,  to 
employ  an  emulsion  of  "pulverized  tubercle  bacilli,  killed  at  59°  F.  by 
repeated  heating,  in  the  unhealed  culture  fluid,  rendered  sterile  by  fil- 
tration through  porcelain.  This  would  mean,  expressed  in  other  terms, 
B.  E.  in  B.  F. 

Next  in  theoretic  value  would  stand  B.  E.,  an  emulsion  which  pro- 
duces at  times  an  unexplainable  reaction,  and  so  presents  more  difficulty 
in  dosage,  and  T.  R.  an  emulsion,  acting  similarly,  of  pulverized  and 
water-extracted  tubercle  bacilli.  It  is  of  interest  to  note  that  Wright's 
results  have  been  obtained  Avith  minute  doses  of  T.  R.,  while  Goetsch 
('01)  was  never  able  to  obtain  a  complete  disappearance  of  tubercle 
bacilli  with  T.  R.,  and  had  to  resort  to  0.  T.,  and  Bandelier  found 
that  T.  R.  produced  much  weaker  agglutination  than  B.  E.  Theobald 
Smith  considers  virulent  uncrushed  tubercle  bacilli,  killed  by  moderate 
heat,  as  the  best  vaccine.  Jousset  has  obtained  good  results  with  a 
culture  that  was  allowed  to  die  in  the  culture  fluid.  B.  F.,  which  is 
unhealed,  diluted  0.  T.,  is  a  weak  tuberculin  less  likel}^  to  produce 
fever  than  general  symptoms  when  carefully  given,  and  an  excellent 
form  for  anyone  beginning  the  use  of  tuberculin.  Spengler's  TOA 
is  really  concentrated  B.  F.  without  the  addition  of  thymol  or  phenol, 
which  he  believes  in  time  gradually  reduces  tbe  strength  of  the  oi'dinary 
B.  F.  His  TOA  produces,  he  says,  fewer  cardiac  syin])toms  than  the 
carbolized  B.  F.  Sahli  is  as  strong  in  his  praise  of  Beraneck's  tuber- 
culin as  Denys  is  of  B.  F. 

Kleljs  was  the  first  to  attempt  to  separate  the  beneficial  from  the 
liai'mful  eom])onents  of  tuI)orcnlin,  l)iit  his  tul)ercnlocidin,  administered 
chiefly  by  mouth,  either  with   <»r   without   sch'niii    (a  derivative   of  liis 


548  SPECIFIC  TREATMENT 

Diplococcus  semilunaris),  has  been  little  used.  Yon  Ruck's  watery  ex- 
tract finds  its  greatest  field  among  the  general  practitioners  of  the 
Southern  States. 

Maragliano's  work  would  suggest  that  B.  F.  might  possess  a  hypo- 
thermic action,  and  in  some  instances  this  undoubtedly  is  true.  Other 
observers  attribute  the  same  action  to  0.  T.,  T.  R.,  B.  E.,  Beraneck's 
product,  etc.  Bandelier  and  Roepke  believe  that  B.  E.  is  the  best  tuber- 
culin, and  that  T.  R.  is  to  be  preferred  to  0.  T.  when  the  antipyretic 
effect  is  desired.  The  separation  of  T.  0.,  which  Koch  thought  to  be 
the  chief  hyperthermic  constituent  of  the  tubercle  bacillus,  from  T.  R. 
does  render  the  latter  of  value  in  some  patients  who  are  unable  to  take 
0.  T.  (Goetsch,  '01;  Bandelier  and  Roepke,  '08),  and  the  same  may 
prove  to  be  true  in  the  case  of  other  forms  of  tuberculin  than  0.  T. 

Finally,  it  may  be  added  that  every  form  of  tuberculin  has  its 
adherents,  who  often  publish  strong  if  not  extravagant  claims  for  the 
preference.  This  fact  leads  many  to  believe,  as  has  been  stated,  that 
little  real  difference  exists  between  many  of  the  tuberculins  (Sahli,  "07). 

DURATION    OF    TREATMENT 

Tuberculosis  is  a  very  chronic  disease,  in  many  instances  extending 
over  four  or  five  years  before  full  recovery  or  death  ensues.  The 
hygienic-dietetic  treatment,  the  so-called  sanatorium  treatment,  has 
clearly  proved  that  long  periods  of  time  (three  or  four  years)  are 
necessary  to  insure  permanent  recovery.  Few  patients,  especially  among 
the  poorer  classes,  can  afford  to  devote  so  much  time  to  seeking  health, 
and  all  recognize  to-day  that  except  for  the  very  well-to-do,  residence 
in  a  sanatorium  until  permanent  recovery  takes  place  is  out  of  the 
question.  Many  sanatoria  limit  the  term  of  residence  to  three  to  six 
months,  and  recognize  fully  that  their  chief  purpose  is  to  start  well 
the  recovery  toward  health  and,  what  is  more  important,  to  inculcate 
ingrained  habits  of  self-restraint  and  hygienic  living.  Tuberculin  treat- 
ment cannot  be  completed  at  such  institutions,  and  many  question  the 
advisability  of  beginning  it  at  all. 

The  same  thing  applies  to  the  tuberculin  treatment  that  applies 
to  the  hygienic-dietetic  treatment  at  these  institutions;  neither  can  be 
completed,  but  the  patients  can  be  so  trained  that  on  their  return  home 
they  can,  when  tuberculin  has  been  found  to  be  helpful,  have  their 
home  physician  continue  the  treatment,  even  while  they  are  at  work. 
They  have  learned  how  they  should  feel;  they  quickly  recognize  the 
essentials  governing  the  increase  of  dose  or  the  cessation  for  a  time  of 
the  treatment.  In  this  way  they  can  aid  immensely  their  family 
physician  in  conducting  the  tuberculin  treatment  at  home  or  even,  as 


DURATION   OF  TREATMENT  549 

some  physicians  have  permitted,  although  this  is  not  advisable,  continue 
to  give  tuberculin  to  themselves  under  the  direction  of  the  sanatorium 
physician. 

From  what  has  been  said,  it  is  clear  that  the  majority  of  physicians 
who  give  tuberculin  hold  that  it  should  be  given,  even  in  incipient 
stages,  over  a  period  of  at  least  six  months,  and  after  an  interval  of 
three  to  six  months  a  second  and  shorter  course  should  be  begim.  It 
is  neither  necessary  nor  advisable  to  discontinue  tuberculin  in  patients, 
especially  those  in  advanced  stages,  who  at  the  end  of  six  or  nine  months 
are  doing  well.  It  may  be  continued  for  twelve  to  fifteen  months  with 
benefit,  but  if  given  too  long  hypersusceptibility  may  occur.  Petruschky 
believes  that  by  stopping  treatment  when  he  reached  a  dose  of  30  to 
50  mgm.,  and  awaiting  the  return  of  susceptibility  to  small  doses,  he 
shortened  much  the  length  of  the  treatment. 

Repeated  Courses. — But  little  evidence  is  at  hand  on  which  to  base 
judgment  of  the  value  of  repeated  courses  of  tuberculin,  first  suggested 
by  Petruschky.  It  is  well  recognized  that  every  tuberculous  patient 
harbors  in  his  body  tuberculous  foci  of  different  ages,  and  for  this 
reason  any  treatment,  unless  it  be  continued  or  repeated  for  months, 
has  been,  except  in  rare  instances,  of  little  avail.  Theoretically,  tuber- 
culin should  be  continued  with  intermissions  of  longer  or  shorter 
duration  until  the  patient  is  cured  or  deriA'es  no  further  benefit  from 
the  treatment.  It  is  not  always  easy,  after  completing  a  course  of  treat- 
ment, to  decide  when  a  new  course  should  be  begun.  If  tubercle  bacilli 
still  occur  in  the  sputum,  a  second  course  should  be  begun  in  three 
or  four  months.  If,  after  a  few  months'  interval,  the  patient  begins 
to  feel  languid  or  to  show  any  other  signs  of  renewed  activity,  a  second 
course  should  be  begun. 

Tuberculin  Test. — If,  however,  tubercle  bacilli  remain  absent  or  no 
change  in  the  physical  signs  or  symptoms  occur,  the  decision  is  more 
difficult.  Petruschky  has  found  that  in  patients  with  tubercle  bacilli 
in  the  sputum,  tuberculin  susceptibility  (to  0.010  c.c.  or  0.001,  0.005, 
0.010,  0.020  c.c.  0.  T.)  returns  in  about  an  average  of  three  months, 
and  he  insists  that  when  tuberculin  susceptibility  returns  the  patient 
is  not  cured  and  should  take  more  tuberculin.  If  absent,  the  test 
should  be  repeated  at  the  end  of  three  more  months,  and  if  reaction  takes 
place  tuberculin  is  given.  Koch  upholds  Petruschky,  and  C.  Spengler 
uses  up  to  10  mgm.  for  this  purpose.  Goetsch  followed  a  similar  course, 
but  subjects  the  patient  to  50  mgm.  0.  T.  Denys,  who  prolongs  his 
first  course  of  B.  F.,  found  reaction  to  0.005  to  0.010  c.c.  of  0.  T.  in 
three  patients  after  five,  twelve,  and  nineteen  months  respectively. 

The  recent  ophthalmo-tuberculin  test  may  prove  to  be  of  value  in 
this  connection,  and  in  four  patients  who  had  taken  1  c.c.  B.   F.  it 


550  SPECIFIC  TREATMENT 

remained  absent  for  three  or  four  months.  It  is  interesting  to  recall 
in  this  connection  the  patient  who  after  repeated  doses  of  0.001  mgm. 
T.  R.  failed  to  react.  Sahli  depends,  in  a  decision  about  a  second 
course,  partly  on  the  slowness  and  length  of  the  first  course,  and  at 
times  gives  it  propliylactically. 

The  second  course  of  tuberculin  can  be  begun  with  higher  doses 
and  given  more  rapidly  than  the  first   (Denys,  '05). 

TREATMENT  DURING  THE  ADMINISTRATION  OF  TUBERCULIN 

Sanatorium. — A  patient  with  tuberculosis  sliould  be  under  the  l)est 
bygienic-dietctic  conditions  possible,  and  these  can  for  most  patients  be 
obtained  more  readily  in  sanatoria.  Many,  however,  cannot  remain 
long  enough  at  a  sanatorium  to  complete  the  tuberculin  treatment,  and 
such  patients  must  be  treated  at  home. 

Rest  and  Exercise. — It  has  been  advised  l)y  some  (Goetsch)  that 
the  patients  remain  in  bed  the  day  of  the  dose  and  the  day  following. 
Were  this  always  necessary,  it  would  debar  many  patients  who  have 
obtained  apparently  great  benefit  from  tuberculin.  It  is  advisable, 
when  possible,  to  curtail  the  exercise  on  the  day  of  the  dose  and  the 
following  day,  but  that  this  is  not  necessary  many  who  give  tuberculin 
to  patients  at  work  have  proved  (Denys,  Krause,  Holdheim,  Heerman, 
Poppelheim,  William  Meyer,  etc.).  In  one  instance  a  patient  who 
had  been  exercising  for  two  hours  a  day  began,  when  taking  0.1  c.c. 
B.  F.,  to  work  six  to  eight  hours  daily.  He  continued  at  work  and 
completed  his  course  of  tuberculin  without  reaction,  but  greater  care 
should  be  exercised  in  dosage  under  these  conditions.  Tuberculin, 
therefore,  may  be  administered  without  injury  to  the  patient  under 
somewhat  adverse  conditions,  providing  always  that  the  patient  get 
sufficient  food. 

Rise  of  Temperature. — A  rise  of  temperature  to  100°  F.  for  more 
than  two  hours  always  means  absolute  rest  in  bed  for  one  or  two  days, 
or  until  the  temperature  is  normal  for  at  least  one  day,  and  a  patient 
with  a  tendency  to  reaction  should  remain  at  absolute  rest  either  in 
his  reclining  chair  or  in  bed  the  day  following  the  dose.  The  severe 
lieadache  accompanying  some  reactions  is  best  treated  by  an  ice  bag 
on  the  head,  but  codein  sulphate  (gr.  ^  q.  2  h.)  may  be  used.  Anti- 
pyretics should  be  used  sparingly  if  at  all. 

Medicinal. — In  conjunction  with  tuberculin  many  substances  have 
been  administered.  Maragliano  uses  a  serum  and  tuherculin  in  alter- 
nating doses.  Eudolph  gives  calcium  carbonate  or  phosphate  in  large 
doses,  which  he  thinks  is  deposited  in  the  tuberculous  focus  during  the 
"  organ "   reaction.      Poeppelmann    rubs   in   iodin,    Wolff   used   iodin, 


EFFECTS   OF   REPEATED    DOSES  551 

Marechal  injects  creosote  jiliosphate,  and   Bernheim  and  Quentin   and 
Pegurier  confirmed  Marechal's  statements. 

Vaccines. — Vaccines  made  from  organisms  recovered  from  washed 
sputum  have  been  employed^  and  Klebs  advocates  the  use  of  selenin, 
an  extract  of  the  Micrococcus  catarrlialis  in  conjunction  with  tuber- 
culoidin. 


EFFECTS  OF  REPEATED  DOSES 

Weight. — Tuberculin  seems  to  exert  little  influence  on  the  general 
condition  and  weight  as  long  as  reactions  are  avoided,  or,  indeed,  an 
occasional  slight  reaction  may  occur  with  little  if  any  harm,  Mitulescu 
found,  following  the  use  of  T.  R.,  a  retention  of  the  nitrogenous 
and  phosphorous  substances  and  so  increased  nutrition,  and  Denys 
('05)  thinks  B.  F.  increases  the  appetite.  Patients  who  were  gaining 
weight  in  the  writer's  experience  seemed  to  continue  to  do  so,  and 
those  losing  weight  were  rarely  affected.  A  few  patients  about  held 
their  own  during  treatment,  but  when  it  was  completed  showed  a 
marked  gain. 

Blood. — Erythrocytes. — An  increase  in  the  number  of  the  erythro- 
cytes after  small  doses  has  been  noted  (Rebaudi  and  Alfonso),  and 
following  severe  reactions  a  reduction  in  the  erythrocytes  may  occur. 
Xo  study  of  the  blood  platelets  has  been  made  in  this  connection. 

Leucocytes. — In  rabbits  Kinghorn  ('02)  observed  first  a  leuco- 
penia,  then  a  leucocytosis,  while  a  study  of  this  subject  in  patients  at 
the  Adirondack  Cottage  Sanitarium  led  Lupton  and  Bro'wn  to  conclude 
that  while  10,000  per  cubic  centimeter  was  rarely  reached,  an  essential 
increase  was  often  present.  In  none  of  their  cases  was  a  marked  leuco- 
cytosis present,  and  in  only  one  or  two  cases  was  a  leucopenia  even 
suggested.  The  differential  count  showed  that  for  rabbits  the  increase 
occurred  in  the  amphophile  cells  while  the  lymphocytes  were  decreased 
(Kinghorn),  while  for  man  the  increase,  according  to  Botkin  ('92), 
occurred  in  all  varieties.  He  obtained  this  when  no  fever  was  present, 
but  he  examined  only  three  patients.  Tschistowitsch  ('91)  found  a 
leucocytosis  after  tuberculin  and  Bischoff  ('91)  found  a  leucocytosis 
in  pulmonary  tuberculosis  after  tuberculin,  but  says  it  often  occurs 
without  tuberculin.  yXrneth,  believing  that  the  neutrophilic  leucocyte 
passes  through  definite  stages  from  a  cell  with  one  nucleus  (young)  to 
a  cell  with  five  divisions  (old),  has  worked  out  definite  "  blood  pictures  " 
for  health  and  for  pulmonary  tuberculosis,  which  differ  widely  in  that 
the  younger  neutropbilcs  arc  in  excess  in  pulmonary  tuberculosis  over 
the  older  and  better  "  trained  "  cells,  and  as  the  disease  progresses  be- 
come more  numerous  still.    Tuberculin,  he  believes,  restores  the  normal 


552  SPECIFIC  TREATMENT 

equilibrium.  A  few  have  confirmed  his  work  in  part.  (Klebs,  A.  C. 
and  H.,  '06.) 

Serum. — The  blood  serum  plaj's  the  most  important  part  in  the 
changes  produced  by  tuberculin.  Arloing  and  Courmont  noted  the 
agglutination  of  a  homogeneous  culture  of  tubercle  bacilli  l)y  the  serum 
tuberculin  and  first  advocated  his  bacillary  emulsion  because  it  produced 
more  agglutination  than  any  other  tuberculin.  The  most  important 
work,  however,  on  the  scrum  has  been  that  of  Wright,  whose  tuberculo- 
opsonic  index  has  been  fully  discussed  elsewhere  (Appendix).  The  op- 
sonic index  to  the  tubercle  bacillus  is  based  on  the  number  of  tubercle 
bacilli  "  phagocyted  "  by  the  polymorphonuclear  cells — cells  probably 
little  concerned  in  acquired  immunity  in  animals.  It  has  not  yet 
been  clearly  proved  that  these  cells  give  a  true  index  of  the  action  of 
tbe  mononuclear  cells,  which  apparently  ^ilay  the  important  role  in  the 
immunized  animals.  During  the  injection  of  small,  well-spaced,  well- 
measured  doses  of  tuberculin  (T.  R.),  the  tuberculo-opsonic  index,  after 
a  preliminary  fall  (negative  phase),  not  always  present,  rises  (positive 
phase)  and  remains  high  for  some  days  (high  tide  of  immunity).  This 
opsonin  is  present  in  normal  individuals,  and  is  apparently  complement, 
as  it  is  thermolabile,  while  in  tuberculous  patients  it  is  thermostable  and 
is  probably  a  specific  amboceptor. 

Blood-pressure. — The  blood-pressure  is  lowered  after  large  experi- 
mental doses,  but  is  unaffected  by  therapeutic  doses  (Bauer,  A.  F. 
Miller). 

Untoward  Results. — The  untoward  results  of  tuberculin  as  clas- 
sified by  Thorner  ('94),  at  the  close  of  the  period  of  "tuberculin 
delirium,''  are  collapse,  impetuous  reaction,  dangerous  swelling  around 
tuberculous  parts  (e.g.,  lar^Tix  and  trachea),  nephritis,  severe  hyper- 
emia of  the  skin  and  brain,  hemorrhages  (of  the  hmgs?),  pneumonia, 
inflammation  of  the  pleura,  mobilization  of  the  tubercle  bacillus,  and 
general  tuberculosis,  and,  according  to  Virchow  ('91),  perforation  of 
the  intestine  when  tuberculous,  and  of  the  lung.  Heron  ('01)  mentions 
several  unfortunate  and  fatal  accidents  following  tuberculin.  A.  Fraen- 
kel  ('91)  reported  a  case  where  the  patient  developed  a  tuberculous 
ulcer  of  the  tongue  that  rapidly  progressed  in  spite  of  tuberculin,  which, 
however,  was  given  while  the  patient  had  a  temperature  of  101.3°  F. 
daily.  Krause  ('00)  has  carefully  reviewed  the  cause  of  the  early 
failure  of  tuberculin  and  decided  that  it  was  due  mainly  to  the  severe 
cases  selected  and  the  doses  and  intervals  used. 

Some  of  the  untoward  results  are  unquestionably  merely  coinci- 
dences. The  writer  had  decided  to  give  two  patients  tuberculin, 
and  in  the  meantime  one  had  a  severe  attack  of  exudative  pleurisy, 
the    other    an    attack    of    hemiplegia.      Trudeau,    Latham,    Marmorek, 


EFFECTS  OF   REPEATED   DOSES  553 

Denys,  Campbell,  Brieger,  Moeller,  and  others  have  all  had  such  ex- 
periences. 

Koehler  ('05)  had  two  cases  of  local  gangrene  after  the  use  of 
tuberculin,  but  later  found  that  he  had  employed  a  diluent  which  con- 
tained a  little  H2SO4.  Sehrwald  had  also  a  case  of  circumscribed  gan- 
grene following  tuberculin.  In  the  writer's  experience  a  sterile  abscess 
developed  after  a  large  dose  of  B.  E.,  but  no  other  untoward  symptom 
occurred  at  the  site  of  the  injection  in  about  10,000  doses. 

Mobilization  of  Tubercle  Bacilli. — The  strongest  objection  urged 
against  tuberculin  has  been  that  it  mobilizes  the  tubercle  bacillus,  and 
many  have  attempted  to  verify  Liebmann's  ('91)  work,  which  disclosed 
countless  numbers  of  tubercle  bacilli  in  the  blood  following  tuberculin. 
In  141  patients  tubercle  bacilli  were  found  56  times.  Barling  and  Wil- 
son found  2  tubercle  bacilli  in  1  and  none  in  3  preparations  from 
one  girl.  Prior  was  able  to  find  none  in  his  patients,  and  Guttmann 
and  Ehrlich  none  in  29  patients.  Kossel  ('91)  in  800  preparations 
found  3  tubercle  bacilli,  1  doubtful  and  2  unverified.  He  also  examined 
Liebmann's  preparations,  found  no  tubercle  bacilli  in  cells,  but  in  dirty 
areas,  and  accused  him  of  using  dirty  slides  formerly  used  for  sputum 
examinations.  Lustig  (quoted  by  Kossel)  found  tubercle  bacilli  in  the 
blood  in  miliary  tuberculosis,  and  more  recently  several  observers  have 
found  with  improved  technic  (inoscopy,  hemolysis,  etc.)  tubercle  bacilli 
in  the  blood  in  patients  not  subjected  to  tuberculin.  Such  results  show 
that  tuberculin  has  no  effect  on  mobilizing  tubercle  bacilli,  for  they 
occur  as  frequently  in  patients  treated  without  tuberculin  as  in  those 
with  if  we  except  Liebmann's  work,  which  has  never  been  confirmed 
and  is  probably  valueless.  Furthermore,  experimental  (Baldwin)  and 
clinical  (Petruschky,  Trudeau,  Wilkinson,  Moeller,  Beck)  evidence  has 
failed  to  show  that  tubercle  bacilli  may  be  disseminated  by  the  use  of 
tuberculin. 

Sputum. — The  cough  and  sputmn  are  frequently  increased  after 
tuberculin,  and  a  feeling  of  oppression  is  also  often  present,  suggesting 
a  congestion.  A  preliminary  increase  of  sputum,  which  may  be  more 
pustular  and  "  dirty,"  is  thought  by  some  to  precede  the  following 
diminution  in  amount.  C.  Spengler  believes  this  increase  may  be  due 
to  the  fact  that  tuberculin  produces  about  the  tubercle  a  specific  sero- 
plastic  inflammation.  The  number  of  leucocytes  in  the  sputum  is  thus 
consequently  increased.    Denys  also  has  noted  this. 

No  effect  can  be  detected  on  the  tubercle  bacillus  other  than  what 
usually  occurs  as  the  sputum  lessens  (i.  e.,  tubercle  bacilli  may  be  more 
numerous  in  the  greatly  reduced  quantity,  or,  in  other  words,  an  appar- 
ent increase  with  a  probable  real  decrease  of  the  number).  The  viru- 
lence is  unchanged  and  the  morphologv  unaffected,  though  Denys  be- 
37 


554  .SPECIFIC  TREATMENT 

lieves  the  tubercle  bacilli  are  longer  and  more  granular,  and  clumping 
is  said  to  be  more  frequent.  Closely  similar  results  have  been  obtained 
by  Pane  working  under  De  Eenzi,  who  has  fully  reviewed  this  subject 
up  to  1894.  Vierling  could  detect  no  definite  changes  in  a  case  he 
carefully  studied.  Phagocytosis  has  been  found,  following  the  injection 
of  tuberculin,  to  occur  less  frequently  by  Allen,  more  frequently  by 
Denys  and  Buchanan. 

Urine. — The  urine  shows  few  changes  except  after  severe  reactions, 
when  it  is  increased  and  may  present  slight  traces  of  albumin  and  a 
diazo-reaction.  The  phosphates  and  chlorids  are  increased  and  urea 
decreased  after  the  first  injection.  Salomon  ('04)  in  experiments  on 
animals  found  that  it  was  very  difficult  to  produce  the  sclerotic  kidneys, 
long  thought  to  be  due  to  the  action  of  tuberculin  (difl'usible  poisons 
of  the  tubercle  bacillus),  and  attributed  the  kidney  degeneration  in  man, 
in  part  at  least,  to  the  action  of  other  toxic  substances.  Grancher  and 
Martin  found  that  their  rabbits,  partially  or  wholly  immune  to  viru- 
lent tubercle  bacilli,  almost  certainly  died  sooner  or  later  of  a  nephritis, 
similar  to  the  epithelial  glomerulo-nephritis  of  scarlet  fever.  According 
to  Eappin  and  Fortineau,  and  Eamord  and  Hulot  (quoted  by  Lubarsch 
and  Ostertag),  the  kidney  epithelium  often  shows  after  the  experimental 
use  of  tuberculin  pronounced  signs  of  degeneration,  due  probably  to  its 
toxic  action.  Denys  has  never  observed  albuminuria  in  any  of  his 
patients  treated  with  B.  F.  Three  patients  out  of  over  200  during  treat- 
ment with  tuberculin  by  the  writer  developed  nephritis;  the  tuberculin 
was  stopped  and  one  made  a  good  recovery.  The  other  two  were  in  a 
far  advanced  stage.  Another  patient  developed  a  fatal  nephritis  one 
year  after  leaving  the  sanatorium,  during  which  period  he  worked  hard 
and  rapidly  declined.  L.  Spengler  believes  T.  E.  is  preferable,  as  he 
found  no  renal  complications  following  its  use,  while  after  0.  T.  eight 
per  cent  of  his  patients  had  albuminuria,  C.  Spengler  states  that  albu- 
minuria is  not  uncommon  after  bovine  tuberculin.  De  Eenzi  ('94) 
reviews  the  work  done  on  the  urine  after  the  use  of  tuberculin  and 
found  the  diazo-reaction  and  albumin  more  frequently  and  urobilinuria 
almost  constantly  present. 

Elevated  Temperature. — The  effect  on  the  symptoms,  except  ele- 
vated temperature,  is  very  difficult  to  determine,  and  even  if  no  results 
are  apparent  it  is  wise  to  continue  the  treatment  if  no  bad  results  are 
noted.  Tuberculin  exerts  on  the  whole  no  marked  effect,  and  the 
improvement  is  no  different  from  what  occurs  in  patients  improving 
and  not  taking  tuberculin — i.  e.,  it  is  by  leaps  and  bounds,  rarely  stead- 
ily onward  to  cure.  A  very  marked  and  immediate  effect  is  seen  on 
the  temperature  in  some  cases,  especially  when  it  does  not  rise  above 
100°  F.     Following  each  dose  of  tuberculin  the  temperature  falls,  and 


EFFECTS   OF   REPEATED   DOSES  555 

in  some  instances  this  is  gradual  until  the  temperature  becomes  and 
remains  normal.  In  others  the  temperature  is  lowered  only  as  long 
as  tuberculin  is  administered. 

Zupnick,  who  is  opposed  to  tuberculin,  frankly  acknowledges  its 
antipyretic  effect.  Aufrecht,  Koch,  Denys,  Elsaesser,  and  many  others 
have  noted  a  similar  action.  Rosenberg  was  nnable  to  detect  any  anti- 
pyretic effect. 

Hemoptysis. — Bandelier  and  Eoepke  believe  that  practically  all 
symptoms  are  improved  by  tuberculin  and  have  never  had  a  recurrence 
of  hemoptysis,  attributing  this  to  a  new  distribution  of  the  blood  due 
to  hyperemia,  which  relieves  the  weakened  vessel.  Goetsch  has  never 
seen  hemoptysis  occur  for  the  first  time  during  tuberculin  treat- 
ment, while  Grasset  has  in  one  case.  It  is  a  striking  fact  that 
tuberculin  does  not  produce  hemopt3'sis  more  frequently  when  we 
consider  the  finer  structure  of  the  lung  and  the  congestion  produced 
by  tuberculin. 

In  all,  11  instances  of  hemoptysis  more  or  less  connected  with,  or 
at  least  following,  tuberculin  (in  one  to  three  days),  have  come  under  the 
writer's  notice.  None  was  severe,  and  most  slight  or  "  streaky."  In 
8  a  previous  hemoptysis  had  occurred,  and  in  only  2  was  there  any 
marked  febrile  movement,  while  in  4  the  temperature  remained  normal. 
In  3  patients  it  rose  to  99.4°,  99.6°,  and  100°  F.  respectively.  When 
it  is  considered  that  in  over  200  patients,  many  well  advanced,  receiv- 
ing about  10,000  injections,  many  of  whom  had  had  previous  hemoptysis, 
this  symptom  was  present  only  11  times,  it  seems  as  if  the  few  hemop- 
tyses  might  be  looked  on,  in  part,  at  least,  as  coincidences. 

Physical  Signs. — The  physical  signs  present  much  fewer  changes 
than  many  hold,  and  improvement  when  it  takes  place  differs  in  no 
way  from  its  usual  course.  Increase  of  physical  signs  after  the  use 
of  tuberculin  occurs  in  some  cases,  possibly  more  often  after  large  doses 
or  certain  forms  of  tuberculin  (watery  extract).  The  local  or  "  organ" 
reactions  occurring  in  patients  with  secondary  infection  (really  ad- 
vanced disease)   are  always  serious. 

Complications. — The  occurrence  of  complications  in  patients  taking 
tuberculin  has  seemed  to  the  writer  to  be  less  frequent  than  in  those 
subjected  only  to  the  hygienic-dietetic  treatment,  and  Bandelier  and 
Eoepke  have  noted  the  same  thing.  When  they  do  occur  the  course, 
unless  benefited  by  tul)erculin,  seems  to  run  as  usual.  Laryngitis  and 
all  forms  of  surgical  tuberculosis  are  apparently  benefited  by  small,  care- 
fully selected  doses  of  tuberculin  when  the  patient  is  in  a  suitable  con- 
dition to  take  tu])orrulin. 

Pathologic  Changes. — Other  pathologic  changes  produced  l)y  tuber- 
culin are  said  to  be  cell  proliferation  if  moderate  doses  be  used,  but 


556  SPECIFIC  TREATMENT 

when  given  in  large  closes  fibrosis  occurs  about  the  foci,  in  the  kidneys, 
and  in  the  liver.  Endarteritis  and  periarteritis  have  been  found.  An 
anatomic  study,  made  by  Pearson  and  Gilliland,  showed  in  all  of  their 
treated  animals  (cattle)  that  the  lesions  had  retrogressed,  were  qui- 
escent, encapsulated,  but  contained  living  tubercle  bacilli,  while  in  the 
untreated  there  was  no  encapsulation. 

Experimental  Results. — The  experimental  basis  for  many  tuber- 
culins is  of  considerable  interest.  Koch  at  first  claimed  excellent  results 
in  guinea  pigs  wutli  0.  T.  which  later  were  not  confirmed.  T.  R.  and 
B.  E.  have  given,  like  0.  T.,  only  partial  immunity  in  small  animals, 
and  some  obtained  none  (Baumgarten,  Arloing,  Courmont,  and  Nico- 
las). These,  as  well  as  many  other  tuberculins  not  used  clinically,  have 
all  been  fully  tested  on  animals.  The  experimental  value  of  von  Ruck's 
watery  extract  rests  on  the  results  obtained  in  six  inoculated  guinea 
pigs  which  outlived  the  controls,  but  were  killed  by  a  dog  and  not 
examined.  Hirschfelder  in  his  first  paper  based  his  claims  on  the 
experimental  results  obtained  in  one  dog.  Sahli  states  that  the  claims 
for  Beraneck's  tuberculin  are  supported  by  excellent  (the  best,  he  be- 
lieves) experimental  evidence.  Denys's  tuberculin  has  no  experimental 
backing,  as  the  author  believes  animal  experimentation  of  little  value 
in  proving  the  worth  of  tuberculin. 

A  careful  survey  of  the  whole  field  of  animal  experimental  research 
on  the  value  of  tuberculin  gives  definite  proof  that  tuberculin  affords 
no  bacterial  immunity,  but  often  prolongs  markedly  the  lives  of  the 
treated  animals,  even  the  most  susceptible,  retards  the  development  of 
the  disease  in  its  earlier  stages,  and  produces  changes  in  the  lesions 
which  demonstrate  an  attempt  at  healing  (Trudeau,  '03,  '06). 

RESULTS 

The  results  obtained  in  the  treatment  of  pulmonary  tuberculosis  by 
tuberculin  would  indicate  that  this  treatment  is  of  value,  and  the  view 
of  the  majority  of  those  who  administer  it  is  decidedly  in  its  favor,  al- 
though some  admit  that  their  figures  do  not  always  bear  out  their  opti:- 
mistic  opinion.  Tuberculin,  Petruschky  ('99)  believes,  can  produce  one 
of  five  things:  (1)  acute  intoxication,  (2)  chronic  intoxication,  (3)  fluc- 
tuation between  immunization  and  intoxication,  (4)  regular  immuni- 
zation, (5)  lack  of  results  due  to  a  too  timid  method  of  procedure. 
Sahli  ('07)  holds,  and  with  considerable  reason,  that  the  results  are  (1) 
cure  (only  in  the  earliest  stages),  (2)  compensation  (equilibrium,  the 
disease  neither  advances  nor  retrogrades),  (3)  the  disease  slowly  ad- 
vances, (4)  no  results.  In  many  instances  it  is  manifestly  unfair  to 
expect  much  from  the  use  of  tuberculin.     The  writer  for  several  years 


RESULTS 


557 


Fig.  148. — Conditions  on  Discharge,  Expressed 
Proportion.^lly,  of  Patients  in  the  Incipi- 
ent Stage,  Treated  with  Tuberculin,  Dis- 
charged Each  Year.  A.  C.  apparently  cured, 
D.  A.  disease  arrested.  Act.,  active.  (Adiron- 
dack Cottage  Sanatorium.) 


selected   severe   types   of   the   disease,   expecting   a    steadily    downward 

progress,  but  on  the  whole  such  patients  have  done  remarkably  well, 

much  better  than  he  dared 

hope.       Such    results    are 

difficult     to     record,     can 

hardly  be  expressed  in  fig- 
ures, but  suggest  that  there 

is  reason  for  the  belief  in 

tuberculin  that  is  gaining 

ground   (see  Figs.   148  to 

151). 

While  prognosis  in  any 

individual  patient  is  most 

uncertain,  the  results  in  a 

large   number   of   selected 

patients  can  be  said  to  be 

practically    always    favor- 
able.   Selection  of  patients 

may,  therefore,  have  some, 

and  in  reality  has  had,  a 

large  part  in  the  favorable 

results  obtained  with  tuberculin.    The  scientific  spirit  seems  sadly  lacking 

in  many  observers  who  have  reported  on  patients  treated  by  this  method. 

It  appears  that  many  be- 
lieve that  a  statement  of 
the  number  of  patients 
and  of  how  many  were 
"  cured,"  "  arrested,"  and 
"  failed "  was  sufficient. 
A  grave  error  may  under- 
lie such  figures.  In  one 
instance  the  patients  may 
all  be  in  such  an  early 
stage  that  an  astonish- 
ingly large  percentage 
must  be  apparently  cured, 
while  in  another  the  pa- 
tients may  be  so  severely 
affected  that  improvement 
of  any  sort  is  almost  im- 
possible.    When  this  error 

is  avoided,  the  patients  are  often  classified  by  some  method  peculiar  to 

the  observer.     Notwithstanding  this,  many  writers  on  the  tuberculin 


Fig.  149. — Conditions  on  Discharge,  Expressed 
Proportionally,  of  P.\tients  in  the  Moder- 
ately Advanced  Stage,  Treated  with  Tu- 
berculin, Discharged  Each  Year.  (Adiron- 
dack Cottage  Sanatorium.) 


558 


SPECIFIC  TREATMENT 


treatment   have  grouped   all    these    patients    together   and   hoped   thus 
to  get  an  idea   of   the  results   of   tuberculin   treatment.      Such  meth- 
ods   easily    lead    to    false 
conclusions. 

When  patients  are  care- 
fully classified  on  admis- 
sion, the  divisions  of  the 
classification  may  be  so 
broad  that  such  selection 
can  be  exercised  as  to  in- 
terfere gravely  with  any 
comparison.  Since  1890 
Trudeau  has  continuously 
used  various  forms  of  tu- 
berculin at  the  Adiron- 
dack Cottage  Sanatorium 
in  spite  of  the  fact  that 
strong  pressure  was 
brought  to  bear  on  him 
to  discontinue  their  use. 
The  patients  subjected  to  tliis  treatment  were  carefully  selected,  and 
until  190'i  only  those  in  good  general  condition  and  without  fever  or 


Fig.  150. — Proportions  of  Dead  and  Living 
IN  1906  OF  All  Those  Treated  with  Tu- 
berculin IN  Each  Year.  (Adirondack  Cot- 
tage Sanatorium.) 


lOOO, 

c— f     ^     ^ 

t      .5      6      y     8      9     to     11     IZ    13    14     15    1 

<i     1 

7     13     19    ZO     21     2Z 

F" 

^"^ 

■*--=- 

90O 

--^^ 

T — 

» 

\\ 

^ 

\. 

^--, 

— 

"^ 

-^^ 



fuK 

y 



80O 

V 

\ 

^. 

^ 

AC 

■ — 

Sen. 

i 

700 

eoo 

\ 

\ 

s 

^ 

500 

w 

\, 

^ 

400 

\ 

-^. 

s 

-^ 

:rr 

^ 

^^ 

\ 

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\, 

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\ 

TnT) 

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r 

?00 

TOO 

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r- 

s 

Tw.A 

rc 

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Act. 

\ 

Fig.  151. — Showing  the  Numbers  per  Thousand  Surviving  at  the  End  of  1, 
2,  3,  ETC.,  Years  After  Leaving  the  Adirondack  Cottage  Sanatorium, 
OF  Those  Who  were  Discharged  Apparently  Cured,  with  Disease  Ar- 
rested, AND  Active.  The  solid  lines  represent  the  total,  and  the  broken  lines 
those  treated  with  tuberculin.  The  dotted  line  shows  the  expected  survivors 
according  to  general  mortality  table.     (Farr,  No.  3.) 


serious  complication  were  given  tuberculin  treatment.     It  was  given  in 
1890  and  1891  to  a  few  patients  in  far  advanced  stages  as  a  last  resort. 


RESULTS 


559 


Since  1902  any  patients  who  wished  tuberculin  received  it,  as  it  was 
hoped  in  this  way  to  avoid  selection,  but  such  has  not  been  the  case. 
Inasmuch  as  patients  who  received  tuberculin  have  been  permitted  to 
remain  longer,  those  who  for  any  reason — e.  g.,  tubercle  bacilli  still 
present  in  the  sputum,  improvement  not  sufficiently  rapid,  the  pres- 
ence of  extensive  lesions,  etc. — desired  to  remain  longer,  elected  to  take 
tuberculin.  Consequently,  while  from  1897  to  1900  a  large  number  of 
incipient  cases  received  tuberculin,  from  1903  on  the  majority  have 
been  moderately  advanced  cases.  This  latter  stage  is  the  broadest  in 
the  classification  used  and  admits  of  far  wider  variation  than  the 
incipient.  Koch's  original  tuljcrculin,  his  bacillary  emulsion,  Tru- 
deau's  modification  B,  Denys's  bouillon  filtrate  and  tuberculo-plasmin, 
have  been  chiefly  used,  but  tuberculin  11  and  tuberculol  have  been  given 
to  a  few  patients. 

While  the  number  of  patients  treated  with  tuberculin  at  the  Adi- 
rondack Cottage  Sanatorium  has  not  been  large,  the  care  with  which 
the  patients  have  been  followed  render  the  following  results  of  in- 
terest. To  allow  of  comparison,  since  the  numbers  in  each  group 
varied  so  much  from  year  to  year,  it  is  necessary  to  reduce  or  to 
increase  the  numbers  of  the  treated  and  untreated  in  each  class  in 
each  year  to  100.  This  gives  the  following  tables,  expressed  in 
percentages,  in  which  are  included  the  results  on  discharge  and  the 
ultimate  results  of  185  patients  treated  with  and  864  treated  without 
tuberculin  who  remained  in  the  institution  over  ninety  days  and 
had  tubercle  bacilli  in  their  sputum : 

Results  on  Discharge 


With  Tuberculin. 

Without 
Tuberculin. 

Incipient: 

Apparently  cured 

Disease  arrested 

56 
34 
10 

27 
55 

18 

50 
38 

Active 

11 

Moderately  advanced : 

Apparently  cured 

6 

Disease  arrested 

51 

Active 

43 

The  ultimate  results,  expressed  in  percentages  of  those  living  one 
to  fifteen  years  after  discharge,  proper  allowance  being  made  for  the 
varying  numbers  in  each  year  and  class,  are  as  follows: 


560 


SPECIFIC  TREATMENT 


Ultimate  Results 


With  Tuberculin. 

Without 
Tuberculin. 

Incipient: 

Apparently  cured 

88 
77 

33 

91 
48 
41 

78 

Disease  arrested 

78 

Active 

27 

Moderately  advanced: 

Apparently  cured 

86 

Disease  arrested.    .         

45 

Active 

22 

These  statistics  indicate  that  on  discharge  the  incipient  cases  have 
done  somewhat  better  than  those  receiving  no  tuberculin,  while  the 
moderately  advanced  cases  showed  much  better  results.  The  ultimate 
results  do  not  show  such  marked  differences,  but  indicate  that  the 
treated,  both  incipient  and  moderately  advanced,  do  better. 

Reports  of  Tuberculin  Treatment. — A  review  of  the  literature  shows 
that  the  lack  of  proper,  or  indeed  of  any,  classification  of  patients  ren- 
ders many  results  of  small  value  for  comparison — e.  g.,  those  of  Amrein, 
Aufrecht,  Beck,  Elsaesser,  A.  Fraenkel,  Heron,  Holdheim,  Kaatzer, 
Krause,  Kreuser,  Schroeder,  and  many  others.  Guttstadt  ('91),  who 
edited  the  first  large  collection  of  reports  on  the  tuberculin  test  and 
treatment  (1891),  reported  figures  during  the  era  of  "tuberculin  delir- 
ium "  and  overdosage.  He  found  only  twenty  per  cent  of  "  cures," 
but  all  stages  were  treated,  and  his  figures  have  little  bearing  on  tuber- 
culin treatment  as  at  present  administered. 

Denison  ('02)  has  reported  213  patients  treated  with  various  culture 
products  and  serums.  His  best  results  were  obtained  with  von  Ruck's 
watery  extract.  Of  33  patients  so  treated,  of  whom  definite  information 
was  given,  28  were  alive  and  5  dead  one  and  two  third  years  after 
treatment. 

Denys  ('05)  reports  442  patients  treated  with  bouillon  filtrate 
(B.  F.).  He  uses  a  personal  classification  both  on  admission  and  dis- 
charge and  compares  the  results  obtained  with  those  secured  in  39  non- 
injected  patients  (Stage  I,  Turban,  afebrile),  of  whom  4  were  healed, 
24  died.  9  failed,  and  2  remained  stationary.  Of  the  442  patients 
treated,  193  (44  per  cent)  were  healed,  56  (13  per  cent)  arrested,  65 
(15  per  cent)  improved,  28  (6  per  cent)  stationary  and  failed,  and  100 
(23  per  cent)  died.  The  striking  feature  of  these  statistics  is  the  fact 
that  all  the  "  controls "  died.  Febrile  patients  were  not  excluded  from 
those  treated  (see  Schnoeller). 

The  results  of  Goetsch  ('01)  have  been  much  quoted  and  received  on 


RESULTS  561 

their  publication  the  indorsement  of  Koch.  He  treated  with  Koch's 
0.  T.  224  patients,  chiefly  in  the  incipient  stage  (88  only  had  tubercle 
bacilli  in  the  sputum,  135  reacted  to  tuberculin,  and  1  had  tubercle  bacilli 
in  the  glands).  Of  these,  12  were  too  short  a  time  under  treatment 
and  in  too  advanced  a  stage  to  obtain  any  results  of  value,  37  patients 
had  just  started  the  treatment,  and  50  were  treated  too  short  a  time. 
These  were  excluded  and  the  remainder  (125),  all  in  the  incipient  stage, 
were  cured. 

Guttmann  and  Ehrlich  ('91)  the  first  to  advocate  small  doses,  gave 
old  tuberculin  to  18  men  and  18  women,  all  afebrile,  13  in  the  incip- 
ient and  23  in  the  moderately  advanced  stage.  They  reported  all  "  prac- 
tically improved."  Inasmuch  as  only  a  small  percentage  of  such 
patients  fail  to  tin  prove  under  suitable  conditions  without  tuberculin, 
these  figures  are  of  small  value. 

E.  Klebs  ("03-4)  uses  a  personal  classification  and  obtains  results 
varying  from  100  per  cent  of  cures  in  his  first  stage  through  90  per 
cent,  57  per  cent  down  to  5.5  per  cent  of  recoveries  for  his  last  stage 
(fourth).  In  his  second  stage  all  improved,  in  the  third  97  per  cent, 
in  the  fourth  33.5  per  cent. 

The  results  of  Langenbach  and  Wolff  ("91)  were  based  on  a  com- 
parison of  99  patients  treated  with  original  tuberculin  and  99  untreated, 
all  in  as  nearly  as  possible  the  same  condition  (many  far  advanced). 
After  a  careful  study  the  authors  conclude  that  those  treated  with 
tuberculin  were  on  an  average  in  slightly  more  advanced  stages  at  the 
beginning  of  treatment.  Of  the  treated  patients  33  were  healed  and  21 
died ;  of  the  untreated  9  were  healed  and  45  died.  Some  of  the  patients 
treated  with  tuberculin  were  also  given  sodium  picrate  and  sublimate 
(corrosive?),  and  these  the  authors  think  did  best.  These  drugs  alone 
were  of  no  value. 

Ludke  ('07)  reported  of  100  patients  treated  with  old  tuljerculin 
(Turban  II,  64,  III,  36)   62  improved  and  11  died. 

Mitelescu  classified  30  patients,  22  with  closed  and  8  with  open  pul- 
monaiy  tuberculosis.  Of  the  former,  20  were  healed,  2  improved;  of 
the  latter,  5  were  healed  and  2  improved. 

The  largest  statistics  so  far  published  of  value  for  comparison,  are 
those  of  Moeller  ('03-4)  at  Belzig.  Only  afebrile  patients,  with  not 
too  far  advanced  laryngeal  and  pulmonary  disease,  without  heart  or 
kidney  disease,  were  given  tuberculin.  Eeduced  to  a  percentage  basis 
the  tabular  comparison  is  as  follows: 


562 


SPECIFIC  TREATMENT 


Stage 
Turban 

No. 

Healed 
(Per  cent) 

Arrested 
(Per  cent) 

Improved 
(Per  cent) 

Unimproved 
OR  Failed 
(Per  cent) 

Tr. 

Untr. 

Tr. 

Untr. 

Tr. 

Untr. 

Tr. 

Untr. 

Tr. 

Untr. 

I 

134 

281 

51 

32 

37 

51 

10 

16 

1 

1 

II 

105 

290 

18 

3 

44 

27 

32 

59 

6 

11 

Ill 

90 

362 

0 

0 

41 

6 

36 

31 

23 

63 

Total.. . . 

329 

933 

27 

10 

40 

26 

24 

35 

9 

28 

Attention  is  here  directed  to  the  marked  advantage  in  favor  of  the 
patients  treated  in  Stage  II.  Stage  I  is  much  wider  than  Trudeau's 
incipient  class  and  shows  correspondingly  a  greater  advantage  in  favor 
of  the  treated.  In  these  stages  careful  selection  may  account  in  large 
part  for  the  differences  obtained.  In  a  study  of  the  tuberculin-treated 
patients  at  Belzig,  Loewenstein  and  Eappoport  state  that  they  consider 
only  those  patients  who  received  at  least  10  mgm.  of  old  tuberculin. 
By  this  selection  all  highly  susceptible  individuals  are  excluded.  If 
this  susceptibility  is  an  indication  of  lack  of  resistance  another  proc- 
ess of  selection  is  exercised.  This  docs  not  hold  for  the  foregoing 
figures. 

Petruschky  divides  his  patients  treated  with  tuberculin  into  open 
(38)  and  closed  (54)  pulmonary  tuberculosis.  In  the  latter  all  were 
healed,  in  the  former  15  were  healed  and  23  are  dead. 

The  results  reported  by  Nagel  ("06)  from  Cottbus  are  apparently 
in  favor  of  the  patients  treated  with  tuberculin.  Here  the  results  ob- 
tained in  Stage  I  (Turban)  closely  approximate  the  results  in  the 
incipient  stage  at  the  Adirondack  Cottage  Sanitarium — i.  e.,  little  dif- 
ference exists  in  the  immediate  result  between  the  treated  and  untreated 
patients.  In  Stage  II,  however,  the  healed  are  three  times  as  numerous 
among  the  treated  as  among  the  untreated,  and  those  able  to  work  fully 
two  thirds  as  many  more  among  the  treated  as  among  the  untreated 
patients.  Stage  III  shows  similar  results.  Tuberculin  has,  however, 
been  administered  at  Cottbus  only  for  three  years  (1902-4).  The 
improvement  in  sanatorium  results  during  recent  years,  due  no  doubt 
to  the  earlier  diagnoses,  is  very  marked.  The  comparison  given,  there- 
fore, is  between  selected  patients  of  later  years  and  those  not  chosen 
for  tuberculin.  These  latter  are  probably  better  than  the  tuberculin 
treated,  and  certainly  no  worse  as  a  whole.  Comparison  of  these  (598) 
with  the  patients  treated  with  tuberculin  (184)  (obtained  by  subtract- 
ing table  of  all  patients  treated  with  tuberculin  from  table  of  all  pa- 


RESULTS 


563 


tients  during  years  in  whicli  tuberculin  was  used)  gives  very  interesting 
results,  shown  in  the  following  table  in  percentages: 


No.  OP 
Patients 

Stage 
Turban 

Healed  and  Able         Partially  Able 
TO  Work            '             to  Work 

Unable  to  Work, 
Worse 

Tr. 

Untr. 

Tr. 

Untr.              Tr. 

Untr.              Tr. 

Untr. 

32 

116 

36 

521 
65 
12 

I 

II 

III 

87 
70 
14 

92 

71 

0 

13 
23 
56 

s 

20 

58 

0 

7 

30 

0.2 

9.0 

42.0 

These  figures  show  very  little  difference  between  the  treated  and 
untreated  patients,  and  would  suggest  that  either  tuberculin  has  exerted 
no  effect  upon  the  immediate  results  or  that  the  patients  subjected  to  the 
tuberculin  treatment  were  worse,  which  Nagel  states  to  be  the  case. 
Patients  with  more  advanced  disease  were  chosen  for  tuberculin  treat- 
ment, and  often  only  those  not  doing  well  under  hygienic-dietetic  treat- 
ment, especially  in  open  pulmonary  tuberculosis  of  the  earlier  stages. 

Eecently  Bandelier  and  Roepke  ('08)  have  published  results  ob- 
tained at  Cottbus  by  the  use  of  B,  E.  and  Perlsucht  0.  T.  The  follow- 
ing table  gives  these  results  as  compared  with  the  nontreated  cases 
referred  to  above: 


Stage 

Results 

Nontreated 

Patients, 

1902-4 

Patients 

Treated  with 

B.  E. 

Patients 
Treated  with 
Perlsucht  O.  T. 

I 

Healed 

212—41% 

265—51%, 

43—  8% 

1—  0% 

10—37% 

12—44% 

5—19% 

0—  0% 

11—34% 

19—59% 

2-  6% 

0-  0% 

Able  to  work 

Partly  able  to  work 

Unable  to  work 

II 

Healed 

5-8% 
41—63% 
13—20% 

6—  9% 

13—10% 

77—62% 

30—24% 

4-3% 

25—21% 
66—56% 

26—22% 
0—0% 

Able  to  work 

Partly  able  to  work 

Unable  to  work 

III 

Healed 

0—  0% 
0-0% 
7—58% 
5—42% 

0—  0% 

9—17% 

35— 65%c, 

10-19% 

0-0% 

t>— 31% 

16—55% 

4—14% 

Able  to  work 

Partly  able  to  work 

Unable  to  work 

For  some  years  von  Ruck  has  reported  no  patients  who  have  not 
received  treatment  with  his  watery  extract,  and  his  figures  therefore 
afford  no  basis  for  comparison  of  treated  and  untreated  patients.  His 
use  of  a  personal  classification  also  renders  comparison  of  his  results 
with  those  of  others  difficult  or  impossible.  He  has  obtained,  he  states, 
excellent  results. 


564  SPECIFIC  TREATMENT 

Schmoeller  ('05)  has  reported  311  patients  treated  with  Denys's 
tuberculin.  Of  these  in  Stage  I  (Turban)  (25)  100  per  cent  improved, 
68  per  cent  were  healed;  of  Stage  II  (121),  94  per  cent  improved,  25 
per  cent  were  healed;  of  Stage  III  (65),  72  per  cent  improved,  3  per 
cent  were  healed. 

Carl  Spengler,  by  the  aid  of  bovine  tuberculin,  obtains  100  per  cent 
of  cures  in  Stages  I  and  II  (Turban)  and  99.7  per  cent  of  cures  in  the 
same  stages  with  tuberculin  from  bovine  and  human  strains.  Such 
figures  need  no  comment. 

Turban's  ('06)  results  are  based  on  the  treatment  of  327  patients, 
241  without  and  8.6  with  tuberculin.  All  had  tubercle  bacilli  in  their 
sputum.  "  Lasting  healing  "  was  obtained  in  53  per  cent  of  the  latter 
and  in  39  per  cent  of  the  former. 

The  idtimate  results  of  tuberculin  treatment  are  believed  by  some 
to  be  the  real  test  of  the  value  of  this  treatment.  The  ultimate  results 
obtained  by  Trudeau  have  been  mentioned.  Heron  treated  32  (un- 
classified) patients  with  tuberculin,  and  seven  years  later  found  10 
well,  1  relapsed,  8  dead,  and  13  untraced.  Holdheim  in  15  unclassified 
ambulant  patients  similarly  treated  obtained  after  two  years  a  negative 
tuberculin  test  and  observed  no  recurrence  of  symptoms.  During  tlie 
winter  of  1890-91  Eembold  treated  82  patients  with  old  tul)erculin. 
Six  years  later  he  traced  70  patients,  27  of  whom  had  had  mixed  infec- 
tions and  had  died  (23  in  the  first  year,  2  in  the  second,  and  2  in  the 
third  year  after  treatment).  Of  the  remainder  (43)  18  were  dead,  12 
improved,  and  13  cured.  Of  the  13  cured  12  had  early  and  10  closed 
pulmonary  tuberculosis.  Three  of  the  12  patients  improved  had  closed 
lesions. 

Loss  of  Tubercle  Bacilli. — The  loss  of  tubercle  bacilli  in  the  sputum 
by  patients  undergoing  treatment  is  evidently  of  the  greatest  importance, 
and  since  it  has  been  roughly  estimated  that  only  42  per  cent  of  patients 
lose  their  bacilli  during  residence  in  a  sanatorium,  it  is  clear  that  any 
treatment  that  will  increase  these  figures  is  of  great  importance,  even 
if  it  accomplished  little  else.  Patients  treated  with  tuberculin  usually 
remain  longer  in  sanatoriums,  a  fact  that  directly  influences  the  dis- 
appearance of  tubercle  bacilli  from  the  sputum.  A  study  at  the  Adi- 
rondack Cottage  Sanitarium  of  the  cases  previously  mentioned  showed 
that  in  the  incipient  class  64  per  cent  of  those  treated  without  and 
67  per  cent  of  those  treated  with  tuberculin  lost  their  bacilli,  while 
for  the  moderately  advanced  the  figures  were  24  and  44.  Bandelier 
and  Roepke  ('08)  have  recently  published  their  results  obtained  with 
B.  E.  and  bovine  old  tuberculin,  which  are  as  follows: 


ANTAGONISTIC   BACTERIA  565 

Percentages  op  Patient-s  who  Lost  Tubercle  Bacilli 


Stage 

B.  E 

Bovine  O.  T. 

I 

100 

100 

II 

78 

90 

III 

34 

39 

Kreuser  selected  110  patients  with  tubercle  bacilli  in  their  sputum 
and  treated  55  without  and  55  with  tuberculin.  Of  the  latter,  23  lost 
their  bacilli,  of  the  former  IG.  Philippi  ('06)  compared  98  patients 
Avithout  tuberculin  treatment  with  28  so  treated  (all  afebrile),  and 
found  in  the  second  stage  (Turban)  19  per  cent  of  the  untreated  and 
58  per  cent  of  the  treated  lost  the  tubercle  bacilli  from  their  sputum, 
while  of  the  third  stage  7  per  cent  of  the  untreated  and  31  per  cent 
of  the  treated  lost  their  bacilli.  Turban  found  at  the  end  of  from  two 
to  six  years  that  48  per  cent  of  the  treated  and  27  per  cent  of  the 
"untreated  had  sputum  free  from  tubercle  bacilli. 

The  present  status  of  tuberculin  may  be  expressed  in  a  few  words. 
Tuberculin  when  properly  given  does  no  harm,  may  produce  no  appar- 
ent result,  and  may  markedly  benefit  an  individual  patient,  who  can 
follow  at  the  same  time  the  hygienic-dietetic  treatment  while  in  a  health 
resort,  at  home  and  at  rest,  or  at  work.  Small  doses  and  careful  increase 
are  most  important,  and  by  following  them  very  closely  some  patients, 
even  in  advanced  stages,  reap  great  benefit.  The  immediate  and  ulti- 
mate results  are  improved,  fewer  relapses  occur,  and  more  patients  lose 
the  tubercle  bacilli  in  their  sputum. 

ANTAGONISTIC    BACTERIA 

(Bacterio-tltcrapi/) 

Bacterium  Termo. — Cantani  ("85)  advocated  spraying  into  the 
lungs  a  culture  of  hacterium  termo,  which  Ravenel  states  has  been 
found  to  be  a  mixture  of  a  number  of  putrefactive  organisms.  This 
treatment  was  based  upon  the  theory  that  putrefactive  organisms  de- 
stroyed tubercle  bacilli,  a  view  that  De  Toma  ('90)  clearly  disproved. 
It  is  useless  to  review  the  work  on  this  subject,  a  task  already  performed 
by  De  Toma  ('8S-'90)  and  Moeller  ('04). 

Erysipelas. — Solles  ('90)  thought  that  erysipelas  prolonged  the  life 
of  tuberculous  guinea  pigs,  a  statement  that  has  aroused  little  interest. 

Syphilis. — Portucalis  is  stated  by  Braunstein  and  Fraenkel  ('01) 
to  have  inoculated  patients   with  lues  to   cure   tul)erculosis.     There  is 


5G6  SPECIFIC  TREATMENT 

no  record  to  show  that  his  temerity  has  l^een  equaled,  and  proof  exists 
to  show  that  SA-philis  is  a  predisposing  factor  to  tuberculosis. 

Yeast. — Tournier  ('00)  stated  that  yeast  had  some  healing  influence 
on  tuberculosis,  and  Huggard  and  Morland  ("05)  have  since  recom- 
mended it  on  account  of  its  rich  content  of  nucleic  acid.  (See 
Koumiss. ) 

Merrihy  ("97)  used  Bacillus  coll  communis  with  good  results,  and 
Moeller  (*04)  sarcina  and  cocci  without  results  and  Bacillus  tumesciis 
and  Bacillus  mesentericvs  with  slightly  favorable  results.  Maher  ('06) 
urged  the  use  of  a  bacillus  found  in  milk  and  elsewhere,  which  he  called 
Bacillus  X.  His  results  have  not  been  confirmed.  There  is  at  hand 
some  evidence  to  show  that  patients  contracting  typhoid  fever  do  remark- 
ably well,  but  no  one  to  the  writer's  knowledge  has  as  yet  suggested  the 
use  of  these  organisms  for  the  cure  of  tuberculosis. 

"Acid-fast"  Bacteria. — Moeller  ('04),  the  authority  on  this  class 
of  organisms,  asserts  that  a  close  relationship  exists  between  them  and 
the  tubercle  bacillus,  and  that  immunization  against  the  one  may  pro- 
tect, in  part,  at  least,  against  the  other.  The  agglutination  test  does  not 
differentiate  them  (Koch),  and  Klemperer  and  Moeller  found  that  the 
timothy-hay  bacilli  offered  some  protection  to  experimental  animals. 
Moeller  found  that  the  more  virulent  members  of  the  group  afforded 
the  better  protection  against  tubercle  bacilli,  but  that  avirulent  indi- 
viduals of  one  species  protected  against  the  virulent  members  of  the 
same  species,  and  homologous  bacteria  were  not  necessary  to  produce 
marked  immunity  against  these  acid-fast  bacteria. 

Attenuated  Tubercle  Bacilli. — The  best  immunity  to  tuberculosis 
has,  as  Trudoau  ('0GB)  has  sho-WTi,  been  obtained  by  living  tubercle 
bacilli,  attenuated  to  a  marked  degree,  but  not  completely  avirulent  for 
guinea  pigs.  These  small  animals  have  not  yet  been  fully  immunized 
against  tuberculosis,  and  the  results  in  rabbits  on  account  of  the  pro- 
nounced natural  immunity  are  often  unsatisfying.  The  human  strain 
of  tubercle  bacilli  have  been  attenuated  by  many  means  (heat,  sunlight, 
decomposition,  long  growth,  unfavorable  media,  passage  through  refrac- 
tory animals,  treatment  with  glycerin,  phenol,  and  various  antiseptics, 
soaking  in  serums  and  in  emulsions  of  lymph  glands),  and  the  tubercle 
bacilli  then  used  for  immunizing  purposes.  Dixon  ('89)  first  obtained 
a  rather  high  degree  of  immunity  to  tuberculosis  in  experimental  ani- 
mals by  preliminary  inoculation  of  attenuated  tubercle  bacilli  (Pearson, 
'Ofi).  Trudeau  ('93)  was  able  to  show  marked  improvement  in  rabbits' 
eyes  by  the  use  of  living  avian  tubercle  bacilli. 

De  Schweinitz  ('94)  reported  marked  immunity  in  a  cow  inoculated 
with  an  organism  attenuated  by  growth  (Trudeau's  R  bacillus),  but 
the  work  of  McFadyean   ('01),  who  used  avian  tubercle  bacilli  intra- 


ANTAGONISTIC  BACTERIA  567 

venoiisly,  was  the  first  to  attract  widespread  attention.  In  December, 
1901,  von  Behring  announced  that  he  was  trjdng  to  immunize  cattle  by 
repeated  intravenous  inoculation  of  attenuated  human  tubercle  bacilli, 
but  Pearson  and  Gilliland  were  the  first  to  bring  forward  proof  sub- 
stantiating such  a  claim.  Later  von  Behring  ('05)  has  put  ujjon  the 
market  his  "  bovo-vaccine,"  a  powder  of  dried  human  tubercle  bacilli 
which  keeps  but  one  month.  "Tauruman"  of  Koch  ('00)  and  Schiitz 
is  a  similar  product,  but  retains  its  virulence  longer.  Both  are  used 
intravenously.  Since  then  Neufeld,  von  Behring,  Hutyra,  and  others 
have  shown  that  cattle  can  be  immunized  against  a  dose  of  tubercle 
bacilli  given  experimentally  and  acquired  naturally  in  infected  stables, 
which  is  fatal  for  controls.  Only  young  animals  which  are  not  to  be 
milked  or  used  for  food  for  many  months  are  suitalile  for  vaccination. 
Calmette  and  Guerin  ('07)  have  obtained  some  immunity  in  calves  by 
feeding  them  dead  tubercle  bacilli. 

Vaccination. — Marfan  ('86)  noted  that  patients,  once  fully  cured 
of  a  local  tulierculosis,  rarely  suffered  again  from  tuberculosis.  Koch 
('90)  had  noted  a  difference  in  local  reaction  in  tuberculous  and  healthy 
guinea  pigs  to  the  injection  of  tubercle  bacilli.  Maragliano  ('01)  more 
recently  has  attempted  to  produce  a  focus  of  tuberculous  inflammation 
in  the  skin  without  the  use  of  living  tubercle  bacilli.  Accordingly,  he 
has  inoculated  individuals  in  the  arm  in  three  places  about  one  and  a 
half  inches  apart  with  1  mgm.  of  dried  tubercle  bacilli  heated  to  150°  C. 
in  glycerin  for  one  and  a  half  hours.  A  small  pustule  with  a  larger 
area  of  induration  accompanied  with  some  fever  for  two  days  occurs. 
This  is  repeated  once  and  no  reaction  follows.  The  value  of  this  has 
naturall}^  not  been  proved  on  man,  but  animals  resist  afterwards  viru- 
lent tubercle  bacilli. 

Other  strains  of  tubercle  bacilli  have  been  used  for  immunity.  Avian 
tubercle  l)acilli  were  first  used  l)y  Trudeau,  Hericourt  ('92),  and 
Paterson,  while  Priedmann  ('03)  has  urged  the  use  of  his  turtle 
tubercle  bacillus,  wliich  was  later  proved  virulent  for  warm-blooded 
animals.  Kiister  ('06)  employed  a  frog  tubercle  bacillus,  Moeller  ('04) 
on  himself  a  tubercle  bacillus  passed  through  the  blind- worm,  while 
Klemperer  ('05)  inoculated  himself  and  five  j^atients  with  living 
bovine  tubercle  bacilli.  Spengler  ('04)  has  done  the  same  thing,  using 
0.5  mgm.  of  living  bovine  tubercle  bacilli  and  experienced  only  ulcera- 
tion at  the  site  of  inoculation.  These  attempts  have  not  been  followed 
up,  as  they  proved  lilllo. 

Products  of  the  Tubercle  Bacillus. — Since  1890  great  attention  has 
been  given  to  the  use  of  the  various  products  of  the  tubercle  bacillus, 
and  more  recently  dead  tubercle  bacilli  have  been  largely  employed. 
Trudeau's    ('06)    experin^ents  have  conclusively  shown  that  attenuated 


568  SPECIFIC  TREATMENT 

tubercle  bacilli  give  the  best  protection ;  then  come  in  order  dead  tubercle 
bacilli  and  the  various  products  of  tubercle  bacilli  known  as  tuberculins, 
which  have  been  discussed  at  length. 

ORGANOTHERAPY 

The  treatment  of  pulmonary  tuberculosis  by  extracts  of  various  tis- 
sues, healthy  and  tuberculous,  has  been  often  attempted.  The  tissues 
most  frequently  employed  have  been  the  lymphatic  glands,  tlie  muscles, 
tlie  lungs,  and  the  blood  cells. 

Lungs. — As  early  as  the  seventeenth  century  (1638)  Eobert  Fludd, 
an  English  physician,  advocated  the  injection  of  sputum  for  the  cure 
of  pulmonary  tuberculosis.  Cavagnis  ('S6)  obtained  with  tuberculous 
sputum,  treated  with  phenol,  favorable  results  in  pulmonary  tul)erculosis. 
Krause  ('06)  injected  subcutaneously  into  one  patient  his  own  sterilized 
tu])erculous  sputum  with  only  slight  rise  of  temperature  and  without 
local  reaction,  and  obtained  pronounced  decrease  of  catarrh  and  marked 
improvement  of  the  general  health. 

Allen  ('07)  advocated  the  use  of  specially  homogenized  and  sterilized 
(by  repeated  lieating  to  60°  C.)  tuberculous  sputum  in  pulmonary 
tuberculosis  more  on  account,  it  is  true,  of  the  homologous  uncul- 
tivated bacteria.  Loewenstein  ('06)  found  that  leucocytes  obtained 
from  the  urine  of  a  patient  with  tuberculous  cystitis  phagocyted  heterol- 
ogous but  not  homologous  tubercle  bacilli,  until  treated  witli  B.  E. 
(heterologous).  Wright  ('07),  who  is  strongly  in  favor  of  homologous 
bacterial  vaccines,  makes  little  or  no  mention  of  it  in  tuberculosis  and, 
in  all  the  vaccines  employed,  cultivation  of  the  organisms  seem.s  in  no 
way  to  decrease  their  effect. 

As  late  as  1897  and  1898,  Lemery  and  Schroeder  advocated  the  use 
of  the  lungs  of  the  fox,  one  cooked,  the  other  as  a  powder.  Some  years 
ago  two  homeopathic  physicians,  Jaeger  and  Burnett  ('00),  advocated 
the  use  of  powdered  tuberculous  pulmonary  tissue  in  the  treatment 
of  tuberculosis,  and  this  substance  in  its  various  "  potencies  "  is  to  be 
found  to-day  in  the  homeopathic  pharmacopoeia.  Allen  ('07  B),  Saranac 
Lake,  was  unable  to  discover  any  tubercle  bacilli  or  their  fragments  in 
the  sugar-coated  pills.  More  recently  Peter  Paterson  ('06)  has  used  the 
caseous  material  from  tuberculous  foci.  Basing  his  work  upon  a  theory 
that  because  tubercle  bacilli  do  not  grow  in  pus  in  abscesses  while  they 
grow  in  the  wall  there  is  some  antagonistic  substance  in  the  caseous 
matter,  he  has  sterilized  this  by  alternate  freezing  and  thawing  for  six 
months.  It  is  then  thoroughly  washed  to  remove  all  soluble  toxins,  and 
an  emulsion  (1  c.c.  =  0.005  gm.)  made  in  salt  solution.  Large  doses 
only  cause  febrile  reaction.     The  best  dose  is  0.1  c.c.  to  0.5  c.c,  which 


ORGANOTHERAPY  569 

should  cause  a  rise  of  0.5°  F.  Five  patients  have  done  well  under  this 
treatment. 

A  criticism  of  all  such  attempts  with  tuberculous  tissue  may  readily 
be  made,  in  that  all  these  tissues  contain  tubercle  bacilli  and  it  is  a  fair 
induction  that  any  benefit  arising  from  such  powders  or  emulsions  may 
be  due  to  the  tubercle  bacilli  or  its  toxins  which  they  contain. 

The  juices  or  extracts  of  normal  lungs  have  also  been  tried.  Bru- 
net  has  found  that  guinea  pigs  inoculated  with  gh^cerin  or  aqueous 
extracts  of  pulmonary  tissue  lived  a  little  longer  than  the  controls,  and 
that  four  patients,  while  experiencing  some  oppression  and  congestion 
(of  the  lung?),  had  less  exjsectoration  and  were  somewhat  improved. 
Grande  has  used  a  pulmonary  extract  and  also  4  to  5  gm.  a  day  of 
powdered  lung  tissue  in  the  form  of  pills,  and  one  patient  so  treated 
improved. 

Lymphatic  Glands. —  (a)  Tuberculous. — Eodet  ('03)  macerated  in 
sterile  water  tuberculous  glands  from  guinea  pigs,  added  thymol  and 
allowed  the  suspension  to  stand  until  the  tubercle  bacilli  were  dead. 
The  results  in  guinea  pigs  were  unfavorable  in  regard  to  treatment,  but 
seemed  to  increase  in  a  certain  measure  the  resistance  to  infection. 
Large  doses  were  employed. 

Bimbaud  ('04)  used  practically  the  same  method  of  preparation, 
but,  on  account  of  induration  at  the  site  of  injection,  he  later  filtered 
the  emulsion  through  paper.  Human  tuberculous  glands  (excised  at 
operation),  as  w^ell  as  tuberculous  glands  from  guinea  pigs,  were  em- 
ployed.    His  results  were  similar  to  those  of  Eodet. 

Baldwin  and  Price  obtained  negative  results  in  guinea  pigs  from 
an  emulsion  of  a  tuberculous  gland  removed  during  the  .  height  of  a 
tuberculin  reaction  from  a  calf,  previously  inoculated  with  virulent 
human  tubercle  bacilli.  McCullough,  who  has  had  good  results  in 
treating  glandular  tuberculosis  with  X-rays,  attributes  it  to  a  setting 
free  of  vaccine,  encapsulated  in  the  gland,  "  in  consequence  of  the  re- 
sorbent  action  of  the  X-rays  on  the  rudimentary  neoplastic  tissue  that 
encapsulates  the  tuberculous  gland."  This  auto-inoculation  with  homol- 
ogous bacteria  raises  the  opsonic  index. 

(&)  Normal. — The  lymphatic  glands  are  said  to  contain  nuich 
nucleic  acid,  which  has  been  shown  to  stimulate  the  formation  of  leuco- 
cytes. Arguing  from  this  and  from  the  fact  that  thyroid  extract  is, 
when  administered  by  mouth,  just  as  efficacious  as  when  injected  sub- 
cutaneously,  Hoffman  had  administered  powdered  bronchial  glands 
dried  in  vacuo  at  a  low  temperature.  His  claims  for  this  powder 
are  absurdly  extravagant.  Several  authorities  have  found  that  tubercle 
bacilli  subjected  to  the  influence  of  material  obtained  from  lymphoid 
organs  for  twenty-two  days  were  greatly  attenuated  (Brieger,  Kitasato, 


570  SPECIFIC  TREATMENT 

and  Wassermann,  quoted  by  Bartel  ('06)  and  Neumann),  and  Bartel 
believes  that  tubercle  bacilli  so  treated  will  prove  an  effectual  vaccine 
material.  Baldwin  has  found  that  opsonized  tubercle  bacilli  are  more 
quickly  fatal  for  guinea  pigs. 

Muscle. — The  muscle  plasma,  ordinarily  termed  fresh  beef  juice,  has 
come  into  much  prominence  since  the  publications  of  Eichet  ('00) 
and  Hericourt  ('00).  They  obtained  striking  results  in  the  treat- 
ment .  of  inoculated  dogs,  many  making  good  recoveries.  Fraenkel  and 
Sobcrnheim  ('01),  and  again  Brown  ('03),  were  unable  to  substantiate 
these  claims. 

In  patients  with  pulmonary  tuberculosis  many  have  obtained  good 
results,  but  tlie  majority  of  observers  attribute  these  favorable  results 
to  its  action  as  a  suraliment.  Some  (Balladere),  however,  still  attribute 
to  the  muscle  plasma  an  action,  bactericidal  and  antitoxic  for  the 
tubercle  bacilli,  while  others  suggest  the  use  of  the  meat  of  immunized 
cattle   (Maragliano). 

Blood  Cells. — Lumiere,  and  later  Gelibert,  have  used  by  intramus- 
cular injection  the  plasmic  contents  of  the  blood  cells  "  of  a  certain 
number  of  animals.,"  calling  the  extract  hemoplase  or  plasmo-therapy. 
In  112  patients  treated  with  this  substance  Gelibert  found  that  only 
9  failed  to  improve.  Baldwin  and  Price  obtained  in  guinea  pigs  nega- 
tive results  from  an  extract  of  the  leucocytes  of  an  immunized  cow. 
Daremberg,  following  Pasteur's  work  in  rabies,  injected  without  results 
an  emulsion  of  the  spinal  cord  of  tuberculous  guinea  pigs  and  rabbits 
into  guinea  pigs  and  rabbits.  An  emulsion  of  marrow  from  a  calf  pro- 
duced no  apparent  results  when  injected  into  guinea  pigs  (Baldwin 
and  Price).  • 

Eimbaud  ('04)  has  made  some  experiments  on  passive  organotherapy, 
using  the  serum  of  a  goat  inoculated  with  the  tuberculous  glands  of  a 
guinea  pig  or  man.  The  results  were  negative.  Haentjens  ('06)  has 
used  two  dogs  and  tuberculous  sputum  in  the  same  way,  and  obtained, 
he  claims,  good  results  in  patients  with  the  serum.  Matsutow  be- 
lieves that  tuljerculin  is  not  the  toxin  of  the  tubercle  bacillus  pro- 
duced in  the  living  organism.  This  real  toxin,  free  from  tubercle 
bacilli,  he  claims  to  have  obtained  in  extracts  of  tuberculous  organs  of 
guinea  pigs,  and  with  it  has  so  immunized  guinea  pigs  that  they  re- 
sisted a  fully  virulent  culture.  The  organs  of  the  goat  and  dog  have 
also  been  used,  but  with  little  effect.  Fauvel  uses  suljcutaneously  in 
animals  extracts  of  the  nasal  and  pharyngeal  mucous  meml^ranes  in 
Hayem's  artificial  serum  with  benefit.  This  preparation,  which  he 
called  paratoxin  T.,  gave  good  results  in  sixty-two  patients. 

Organotherapy,  active  or  passive,  in  pulmonary  tuberculosis,  rests  to- 
day upon  little  sound  favorable  evidence,  and  occupies  in  the  specific 


SEROTHERAPY  571 

therapy  of  pulmonary  tuberculosis  a  position  demanding  on  its  prac- 
tical side  little  or  no  consideration. 

HEMOTHERAPY 

Hemotherapy,  first  employed  by  Fiedler  ('70),  using  defibrinated 
blood  of  immune  animals,  and  later  by  Hericourt  and  Richet  ('88-'90), 
has  chiefly  an  historical  interest,  since  Bouchard,  Buchner  and 
others  showed  that  the  senim  contains  practically  all  the  immuniz- 
ing elements  of  the  entire  blood.  The  first  investigators,  basing  their 
experiments  upon  the  fact  that  dogs  are  refractory  to  tuberculosis,  in- 
jected dogs'  blood  into  the  peritoneal  cavity  of  rabbits  and  rendered 
them  more  refractory  to  tuberculosis.  Bernheim,  having  found  the 
goat  very  refractory  to  tuberculosis,  used  intravenous  injections  of 
goats'  blood  in  13  patients.  Of  11  in  the  "  first  and  second"  stages,  7 
were  cured,  4  greatly  improved,  while  2  in  the  "  tliird  "  stage  died,  1 
from  syncope  during  the  transfusion.  Bertin  and  Picq  injected  goats' 
blood  in  the  subcutaneous  and  muscular  tissue  of  the  buttock  in  150 
patients  with  good  results,  save  in  a  few  who  overexercised  and  devel- 
oped abscesses  and  urticaria. 

Figari  has  obtained  increased  antitoxic  and  antibacillary  sub- 
stances in  the  serum  of  18  patients  (5  cured,  13  greatly  improved), 
who  were  given  pulverized  l)lood  clots  to  which  had  been  added  glycerin 
and  aromatics.  Similar  results  were  obtained  with  guinea  pigs.  The 
immunizing  substance  is  in  the  hemoglobin,  Figari  holds.  Ricci  ob- 
tained poor  results  in  three  cases,  but  upholds  the  views  of  Figari. 
Xiccolini,  who  similarly  prepared  and  administered  blood  clots  from 
immunized  calves^  observed  in  patients  increased  weight  and  increased 
agglutinating  power  of  the  serum.  He  gave  7  patients  Maragliano's 
hcmoantitoxin  in  doses  of  15  c.c.  or  less^  according  to  age,  and  ob- 
tained healing  in  4,  improvement  in  2,  while  1  died.  Hemoplase,  the 
plasmatic  content  of  hemoglobin,  gave  good  results  according  to  Lu- 
miere,  quoted  by  Gelibert. 

Since  the  work  of  Boucliard,  which  showed  that  all  the  immunizing 
properties  of  the  blood  are  contained  in  the  serum,  little  interest  has 
been  taken  in  hemotherapy,  and  in  the  liglit  of  our  present  knowledge 
of  agglutinins  and  precipitins  the  blood  should  not  be  used  for  immu- 
nizing purposes. 

SEROTHERAPY 

Passive  immunization  by  means  of  serums  of  treated  animals  has 
been  attempted  by  many,  more  especially  since  Behring's  and  IJoux's 
successful  work  in  diphtheria.     The  first  work  was  naturally  with  the 


572  SPECIFIC  TREATMENT 

serums  of  animals  immune  to  tuberculosis,  which  Bouchard  ('93)  by 
experiments  on  guinea  pigs  sliowed  of  little  value.  This  again  turned 
attention  to  organotherapy,  which  in  turn  was  supplanted  by  the  use  of 
serums  of  artificially  immunized  animals.  The  tirst  work  along  these 
lines  was  that  by  Auclair  ('96),  who  immunized  fowls  to  human  tubercle 
bacilli,  but  obtained  no  antitoxic  serum.  Following  this,  many  attempts 
have  been  made  to  obtain  such  a  serum,  but  to-day,  while  several  men 
claim  to  have  such  a  serum,  they  have  so  far  been  unal^le  to  establish 
their  claim. 

The  amount  of  work  and  literature  upon  this  subject  is  overwhelm- 
ing, and  can  only  be  touched  on  summarily. 

Among  the  animals  used  for  the  production  of  an  immune  serum 
are  fowls,  the  horse,  mule,  ass,  goat,  dog,  sheep,  and  cattle  (milk). 
These  animals  have  been  inoculated  with  many  products  mentioned  un- 
der hemotherapy  and  organotherapy,  with  tubercle  bacilli,  virulent  and 
attenuated  by  many  means  (long  growth,  passage  through  refractory 
animals,  glycerin,  heat,  decomposition,  sputum  treated  with  phenol, 
etc.),  of  all  strains,  human,  bovine,  avian,  and  cold-blooded;  with  many 
varieties  of  tuberculin  (0.  T.,  T.  K.,  B.  E.,  Beraneck's,  etc.) ;  with  acid- 
resisting  bacilli  (timothy  hay). 

Varieties. — The  immunizing  serums  in  use  at  present  have  dwindled 
down  to  very  few.  Those  most  used  are  Marmorek's  ('03,  '04,  '05)  and 
Maragliano's,  but  de  Schweinitz,  Fisch,  Paquin,  Arloing,  Baumgarten, 
von  Behring,  have  also  worked  on  serums.  Monard,  Blache,  and  others 
have  prepared  and  used  artificial  serums;  others  have  combined  iodoform 
and  guaiacol  with  serums.  The  scrum  of  the  normal  horse  and  the 
diphtheria-antitoxic  serum  have  been  advocated.  The  milk  of  immu- 
nized animals  (cows  chiefly)  has  also  been  emplo^-ed. 

Administration. — The  method  of  administration  was  at  first  entirely 
subcutaneous,  but  more  recently  serums  have  been  extensively  used  per 
rectum  (Chantemesse,  '96),  and  many  given  per  os.  Maragliano  and 
several  of  his  pupils  claim  to  have  given  intrapulmonary  injections  with 
benefit.  Large  quantities  of  serum  (one  eiglith  of  tlie  body  weight  of  a 
rabbit)  can  be  administered  to  some  animals  without  any  apparent  in- 
jury (Heilner).  The  use  of  serums  by  mouth,  especially  in  the  case  of 
milk  of  immunized  cows,  has  led  to  much  work.  It  may  now  be  stated 
that  only  during  the  first  two  or  three  weeks  of  life  can  antitoxic  serums 
be  absorbed  by  intact  mucous  membranes,  and  Salge,  quoted  by  Ham- 
burger ('05),  has  shown  that  diphtheria  antitoxin  is  not  absorbed  from 
milk  by  infants,  which  leads  Hamburger  to  doul)t  if  foreign  ahmuiins 
in  cows'  milk  are  ever  absorbed.  It  is  possible,  but  not  probable,  tliat 
antituberculosis  serums  may  act  differently  from  others.  Jemma  has 
found  that  infants  acquire  no  increased  agglutination  after  using  im- 


SEROTHERAPY  573 

mime  milk  unless  the  parents  be  tuberculous.  Maragliano  and  Figari 
deny  these  assertions. 

Results. — Tlie  results  of  passive  immunization  are  neither  brilliant 
nor  promising.  The  injection  of  a  serum  produces  a  ferment  in  the 
blood,  not  usually  present,  and  dependent  only  upon  the  presence  of  the 
peculiar  proteid  injected  (Heilner).  Many  of  the  serums  advocated 
for  use  in  man  rest  upon  little  or  no  experimental  basis,  and  this,  coupled 
with  the  facts  that  normal  serum  of  one  species  of  animal  may  stimu- 
late slightly  the  blood-forming  organs  of  another  and  so  increase  re- 
sistance to  infection  (Weigert),  and  that  suggestion  cannot  be  elim- 
inated, throws  much  doubt  upon  the  results  of  many  observers.  Trudeau 
and  Baldwin,  Arloing,  Mafucci  and  Di  Vestea,  Sokolowski,  Karwacki 
('05),  and  others  have  either  obtained  no  proof  of  antitoxic  substances 
or  no  beneficial  clinical  results. 

Serum  Disease. — ^The  "  serum  disease "  (v.  Pirquet  and  Schick 
('05))  manifested  in  man  by  urticaria,  arthralgia,  and  fever,  occurs 
usually  ten  to  twelve  days  after  the  injection  of  a  serum.  The  "  Theo- 
bald Smith"  phenomenon,  anaphylaxis  to  serum,  described  by  Eosenau 
and  Anderson  ('08)  in  America  and  Otto  ('04)  in  Germany,  occur- 
ring violently  and  fatally  in  guinea  pigs  if  an  interval  of  eight  to  thir- 
teen days  be  suffered  to  elapse  between  the  first  and  second  injections, 
rarely  occurs  severely  in  man,  and  needs  little  consideration  in  most 
patients.  Calcium  salts,  as  Wright  ('96)  suggested,  lessen  the  S3anp- 
toms  in  man.  The  injection  of  any  serum  into  the  veins  causes  severe 
collapse  and  cyanosis,  and  every  care  should  be  taken  to  avoid  this,  for 
at  least  one  fatal  case  has  occurred. 

Marag-liano's  Serum. — Maragliano  in  1895  first  began  to  publish  his 
results  with  his  antituberculosis  serum,  and  from  that  time  to  1900  he 
wrote  twenty-three  articles,  and  others  brought  up  the  list  to  one  hun- 
dred and  eighty-two  papers  on  this  senim. 

In  immunizing  animals  (usually  the  horse,  cow,  or  calf),  Maragliano 
used  sul)cutaneously  increasing  quantities  of  (1)  his  watery  extract 
and  tlie  filtrate  through  porcelain  of  virulent,  living  cultures,  together 
with  the  (2)  bacillary  pulp,  a  filtrate  through  porcelain  of  tubercle 
bacilli  ground  in  sand  and  water.  Equal  quantities  of  these  two  sub- 
stances are  injected  simultaneously  in  different  parts  of  the  body.  If 
borne  without  marked  fever  or  local  reaction,  a  second  injection  of 
double  the  amount  is  made  after  three  days.  The  dose  is  steadily  in- 
creased until  the  serum  of  the  animal  has  a  high  agglutiiuition  and  ])ro- 
tective  power — i.  e.,  until  the  serum  is  of  such  a  ])Ower  that  -nunr  C-C.  will 
protect  1  gm.  guinea  pig.  The  test  poison  is  the  watery  tuberculin,  which 
is  so  concentrated  that  doses  of  one  per  cent  of  body  weiglit  will  kill  a 
guinea  pig  not  sooner  than  twenty-four  hours  nor  later  than  five  days. 


574 


SPECIFIC  TREATMENT 


The  administration  of  the  serum  has  l)een  chiefly  siihciitaneons,  1  c.c. 
every  second  day  for  ten  days,  then  5  c.c.  every  second  day  for  ten  days, 
next  10  c.c.  every  second  day  for  twenty  days  more.  More  recently 
Maragliano  has  advocated  its  use  by  mouth,  Livierato  has  injected  it 
into  the  lung,  and  Hegar  has  painted  it  upon  exposed  tuberculous  areas 
— all,  they  claim,  Avith  good  results. 

Any  case,  Maragliano  says,  is  suitable  for  treatment,  and  many 
good  results  are  obtained  in  patients  who  continue  to  work  and  follow 
few  hygienic  rules. 

The  serum,  according  to  Maragliano,  is  both  antitoxic  and  bacteri- 
cidal; it  reduces  fever,  lessens  the  "number  of  tubercle  bacilli,"  in- 
creases the  weight  and  abates  symptoms.  Hegar  believes  it  acts  only 
on  the  toxins.  Karwacki  ('05),  who  experimented  with  the  serum,  came 
to  the  following  conclusions:  Maragliano's  serum  is  more  poisonous 
to  guinea  pigs  than  normal  horse  serum.  Tlie  serum  contains  no 
antiprotein,  and  does  not  protect  the  guinea  pig  from  a  letlial  dose 
of  tuberculin,  but  ratlier  it  hastens  death  through  acute  intoxica- 
tion. The  serum  has  no  higher  agglutinating  properties  than  normal 
horse  serum.  The  serum  contains  specific  amboceptors,  and  in  the  ani- 
mal organism  gives  rise  to  bacteriolysis  of  the  tubercle  bacilli.  The 
serum  when  injected  together  with  tubercle  bacilli  protects  from  anatom- 
ical tuberculosis,  but  not  from  protein  intoxication.  The  serum  has  an 
unfavorable  action  on  tuberculosis  in  process  of  evolution. 

The  results  obtained  by  Maragliano  ('05)  and  bis  confreres,  from 
1895  to  1905,  in  1,16-1  patients  ma}^  ])e  grouped  as  follows: 


Total. 

Healed. 

Per  Cent. 

Destructive  lesion  with  cavity 

102 
164 
206 
191 
191 
250 

.3 
17 
19 
26 
68 
45 

2 

Destructive  lesion  without  cavitv 

10 

Diffuse  lesion  with  fever ' 

9 

Diffuse  lesion  without  fever 

Limited  lesion  with  fever 

14 
56 

Limited  lesion  without  fever 

58 

These  results  are  good,  Imt  are  no  better  than  many  ol)tain  witliout 
specific  treatment.  In  tliis  country,  l^nvenel,  Walsh,  Landis,  and  Stan- 
ton, at  tlie  Pliipps  Institute,  obtained  no  definitely  beneficial  results. 
Eavenel,  who  has  Avorked  with  Maragliano,  is  convinced  that  tliis  serum 
will  protect  animals  from  fatal  doses  of  tubercle  Ijacilli,  but  is  not  so 
sure  of  its  curative  properties. 

Marmorek's  Serum. — Marmorek  in  1903  resigned  from  the  Pasteur 
Institute  to  present  to  the  French  Academy  of  Medicine  his  discoveries 
in  regard  to  the  antitu])erculosis  serum  now  bearing  his  name.  He 
stated  that  tuberculin  was  not  the  true  toxin  of  tuberculosis ;  that  young 


"FALSE   SPECIFICS"  575 

(primitif)  tiil)crele  l)acilli  excreted  no  tiibercnlin,  but  a  different  toxin; 
that  by  the  use  of  a  medium  consisting  of  a  mixture  of  leucoc3'tic 
serum  (from  a  calf  injected  with  guinea-pig's  leucocA'tes)  and  of  glycer- 
inated  li^er  bouillon  ho  could  obtain  these  young  forms  in  sufficient 
quantities  to  immunize  a  horse  whose  serum  was  strongly  antitoxic. 
The  serum  was  first  advised  to  be  used  subcutaneously,  but  later  has 
been  given  per  rectum,  in  doses  of  5  or  10  c.c.  every  day  for  three  weeks, 
omitted  for  two  weeks  and  then  repeated.  A  cleansing  enema  should 
be  first  given. 

The  results  are  very  difficult  to  determine.  Monod  ('07),  who  is  in 
favor  of  it,  has  reviewed  the  literature  up  to  1907,  and  states  that  tliirty- 
eight  out  of  forty-three  papers  were  in  favor  of  it.  Closer  analysis  than 
this  cannot  be  made  of  these  results,  and  the  fact  that  other  workers 
(Roux,  Borrel)  at  the  Pasteur  Institute  were  unable  to  confirm  his  fun- 
damental experiments  has  thrown  grave  doubt  upon  this  serum.  Accord- 
ing to  some  observers,  normal  horse  or  any  foreign  serum  has  a  stimu- 
lating eifect  upon  patients  (Weigert),  and  this  with  suggestion  may  in 
part  at  least  account  for  the  results.  As  is  usual  with  all  remedies,  the 
s}anptoms  and  signs  are  said  to  decrease  markedly  under  Marmorek's 
serum,  but  Levin  has  found  that  in  guinea  pigs  it  retards  the  growth  of 
tlie  tul)ercle  bacilli  and  neutralizes  the  poison.  Notwithstanding  the 
numerous  "  testimonials  "  from  many  sources,  this  and  all  other  serums 
for  use  in  tuberculosis  must  still  be  considered  in  the  experimental  stage. 

TjTidale  ('00)  suggested  the  use  of  pure  vaccine  l3"mph,  and  a  few 
used  it,  but  without  avail.- 

The  serous  exudate  from  blisters  has  been  used  by  Margant,  and  the 
injection  of  a  small  quantity  of  pleural-serous  effusions  under  the  skin  is 
said  to  hasten  their  absorption.  Flick  and  others  advocate  the  produc- 
tion of  blisters  in  order  to  allow  absorption  of  the  contents,  and  thus  to 
inoculate  tlie  patient  witli  an  homologous  serum. 

Antistreptococcic  Serum. — The  use  of  antistreptococcus  serums  (Mar- 
morek,  Aronsohn,  Menzer,  etc.)  have  been  much  vaunted  by  some  observ- 
ers as  exerting  a  "  specific  "  action  upon  phthisis,  which,  they  say,  is  due 
to  a  secondary  infection  with  streptococci  and  other  organisms.  The 
results  are  not  promising,  and  the  premises  not  always  sound.  "  Mixed 
infection  "  has  been  made  the  scapegoat,  as  Sahli  says,  for  many  failures 
in  tuberculin  and  other  treatments  of  tuberculosis. 

"FALSE    SPECIFICS" 

The  history  of  the  use  and  advocacy  of  "specifics"  in  the  treatment 
of  tuberculosis  long  antedates  the  discovery  of  tlie  tubercle  bacillus,  and, 
in  fact,  takes  us  back  to  the  time  when  the  memory  of  man  runneth 


576  SPECIFIC  TREATMENT 

not  to  the  contrary.  Indeed,  in  the  history  of  no  disease  are  there  re- 
corded more  "  specifics,"  advocated  in  many  instances  by  men  of  higli 
reputations,  who  were  misled  by  tlieir  own  enthusiasm  and  by  the  un- 
consciously imparted  suggestion  to  the  patients.  In  less  enthusiastic 
hands  the  period  of  infatuation  following  the  announcement  of  some 
new  drug  of  great  potency  is  shortly  followed  by  disenchantment,  disuse, 
or  even  oblivion,  justly  merited  in  many  instances.  These  substances 
have  been  well  named  "  false  specifics." 

Tlie  "  antiseptic  treatment "  of  pulmonary  tuberculosis,  based  on  the 
idea  that  it  is  possible  to  destroy  the  tubercle  bacillus  in  situ  without 
harming  the  tissues,  needs  only  to  be  mentioned  to  be  dismissed.  Fur- 
thermore, many  of  the  tubercle  bacilli,  embedded  in  thick  fibrous  tissue 
or  even  caseous  matter,  have  little  or  no  direct  communication  with  the 
air  (inhalation),  or  with  the  blood  or  lymph  current.  The  view  that 
healthy  contiguous  parts  may  be  protected  in  this  way  has  never  been 
proved  by  clinical  experience,  either  in  pulmonary  or  localized  surgical 
forms  of  tuberculosis.  No  medicinal  substance  has  been  found  to 
neutralize  the  tuberculous  toxin. 

Many  drugs  have  been  given  empirically  (iodin,  mercury,  arsenic, 
antimon}^,  etc.),  but,  since  the  discovery  of  the  tubercle  bacillus,  experi- 
mental research  has  been  frequently  employed  in  studying  their  effects. 
Neither  guinea  pigs  nor  rabbits  are  altogether  suitable  for  such  work; 
the  former  are  too  greatly,  the  latter  too  slightly,  susceptible  to  tuber- 
culosis. The  older  work,  based  entirely  upon  the  effect  of  substances 
upon  the  tubercle  bacillus  in  vitro,  has  been  largely  abandoned,  and 
inhalations  and  injections  of  many  antiseptic  substances  are  now  recog- 
nized, as  far  as  they  exert  any  action  upon  the  pulmonary  tuberculosis, 
as  of  no  specific  value. 

Creosote  and  its  Derivatives. — Among  the  most  used  of  all  the  false 
specifics  in  pulmonary  tuberculosis  stand  these  drugs.  They  have  never 
been  proved  to  exert  any  action  whatsoever  upon  the  tuberculous  process, 
but  in  some  patients  have  almost  a  specific  action  upon  the  accompanying 
secondary  infections  of  the  lungs,  such  as  simple  bronchitis.  They  also 
exert  a  very  stimulating  effect  upon  the  bronchial  mucous  membranes 
during  their  excretion  tlirough  it.  For  this  effect  small  doses  only  are 
necessary  in  most  patients  (for  example,  3  or  5  TTL  of  beechwood  cre- 
osote, or  creosotal,  tliree  times  a  day  for  some  weeks,  etc.)  and 
Sommerbrodt's  dictum  that  the  larger  tlie  daily  dose  the  better  the 
results  can  now  be  refuted.  One  gram  (15  gr.)  of  creosote  (1  to 
4,000  in  the  circulating  blood)  at  least  is  necessarj'-,  judging  from 
experiments  in  vitro,  to  exert  any  influence  upon  the  tubercle  bacil- 
lus, and  to  maintain  it  at  this  level  would  require  many  times  the 
dose   that   injures  most   patients.     When   the   tissue   fluid   and   lymph 


"FALSE   SPECIFICS"  577 

are  taken  into  consideration,  the  absurdity  of  such  attempts  becomes 
apparent. 

It  lias  long  been  known  that  the  coml)ination  of  small  doses  of 
creosote  with  cod-liver  oil  often  render  the  oil  more  easily  digested, 
which  is  due,  no  doubt,  to  the  stimulating  effect  of  the  small  quantity 
of  creosote  (drop  doses)  on  a  poorly  secreting  stomach.  The  substances 
have  been  said,  but  not  proved,  to  increase  the  agglutinating  power  of 
the  blood  serum,  to  favor  phagoc3'tosis,  and  to  act  upon  the  tubercle 
toxins. 

Guaiacol,  more  toxic  than  creosote,  has  been  used  for  the  reduction 
of  fever  (painting  the  skin  with  1  gm.  or  less  of  pure  guaiacol,  or  of 
1  c.c.  of  a  twenty- five-per-cent  solution  in  alcohol),  or  for  analgesia  in 
complicating  neuritis  or  intercostal  neuralgia.  In  larger  doses,  repeated 
daily,  it  may  produce  collapse,  and  cannot  be  recommended.  Like 
creosote  it  has  been  administered  by  inunction,  by  injection  (subcutane- 
ous, intratracheal,  intrapulmonary,  and  per  rectum),  or,  preferably,  per 
OS  in  capsules.  Gluten-coated  pills,  insoluble  in  the  stomach,  or  gelatin 
globules  or  capsules,  are  the  best  way  in  wliich  to  administer  creosote. 
Flick  advised  rather  large  doses  in  water  one  hour  before  meals.  The 
contraindications  include,  among  others,  fever,  persistent  tachycardia, 
and  hemoptysis,  but  a  persistent  taste  of  creosote,  gastric  irritation,  and 
nephritis  are  of  more  importance.  The  patient  should  always  be  warned 
to  stop  it  or  any  medicine  if  the  slightest  digestive  disturbances  occur. 
Only  pure  beechwood  creosote  should  be  used,  but  several  instances  of 
poisoning  from  the  usual  doses  have  been  recorded. 

The  derivatives  of  creosote  are  increasing  daily,  and  the  following 
list  includes  only  some  of  the  more  important:  Creosotal  (creosote  car- 
bonate, 93  per  cent  creosote),  less  irritating  than  creosote,  5  or  more 
drops  in  capsules,  etc.,  p.  c. ;  duotal  (guaiacol  carbonate,  90  per  cent 
guaiacol),  5  to  15  gr.  (0.3  to  1.0  gm.)  in  capsules  p.  c. ;  thiocol  (potas- 
sium guaiacol  sulphonate,  60  per  cent  guaiacol),  a  nonirritating,  nontoxic, 
odorless,  tasteless  powder,  soluble  in  water;  sirolin,  10  per  cent  thiocol 
in  orange  sirup,  5  to  10  gr.  or  more  (0.3  to  0.6  gm.)  p.  c. 

Gomenol  (Dubousquet  and  Laborderie,  '05),  distilled  from  selected 
leaves  of  meJalcuca  verdifiura,  and  consisting  in  large  part  of  a  terebene, 
eucalyptol,  citrene,  and  terpincol,  is  nontoxic,  can  be  used  subcutane- 
ously  or  per  os,  and  has  much  the  same  effect  as  creosote,  but  is  less 
irritant. 

Arsenic  and  its  Derivatives. — Arsenic  has  been  held  by  some  to  act 
as  a  specific  in  pulmonary  tuberculosis,  and  in  this,  as  in  some  other 
chronic  nervous  and  wasting  diseases,  it  stimulates  nutrition  remark- 
ably. It  has  long  been  used  in  anemic  patients  successfully,  but  in  fever 
the  results  are  questionable.  It  may  be  given  as  sodium  or  strychnin 
38 


578  SPECIFIC  TREATMENT 

arsenate  (gr.  ^V  ^^^  i)>  ^^  ^^  Fowler's  solution  (gtt.  ij,  or  more  p.  c). 
The  latter  has  been  combined  with  a  tincture  of  iron  or  iron  arsenate 
(gr.  yV  to  I,  0.004  to  0.008  gm.),  and  has  been  administered  alone  in 
anemic  patients  with  good  results.  The  cacodylates  (sodium,  strychnin, 
guaiacol,  iron),  first  advocated  by  Gautier,  and  containing  54  per  cent 
of  arsenic,  can  be  given  in  large  doses  hypodermically  (up  to  4  eg.  (6 
gr.)  p.  d.),  but  are  very  little  absorbed  (Fraser),  and  in  some  patients 
produce  disagreeable  symptoms,  such  as  garlicky  odor  of  the  breath,  ex- 
foliative dermatitis,  etc.    A  useful  formula  for  subcutaneous  injection  is : 

I^   Morphinae  hydrochloratis   gr.  ss. ;  .03  gm. 

Cocainae  hydrochloratis    "  Jss. ;  0.1     " 

Sodii   chloridi    "  iij ;  0.2     " 

Sodium  cacodylatis   "  xxv;  1.5     " 

Phenol    ^t-  ij ;  gtt.  ij 

Aqua  destil q.s.ad.  jiijss. ;  104  gm. 

The  beginning  dose  is  usually  0.5  c.c.  (7|  TTt)  twice  a  day  for  six 
days,  then  thrice  a  day  for  three  to  five  days.  After  an  omission  of 
several  days  the  treatment  is  again  begun.  The  results  are  not  highly 
satisfactory,  though  it  may  be  tried  if  arsenic,  when  found  to  be  bene- 
ficial, cannot  be  taken  continuously  by  mouth.  Disorders  of  the  liver 
and  continued  gastric  or  intestinal  disturbances  are  contraindications 
to  arsenic  in  any  form.  It  lias  been  advised  to  administer  arsenic  only 
in  early  or  quiescent  stages.  Histogenol  (sodium  methylarsenate  and 
nucleic  acid),  arrhenal  (monomethyl  arsenate,  atoxyl,  and  vanadium) 
have  been  used. 

Alcohol. — Alcohol,  formerly  considered  a  specific  in  pulmonary  tuber- 
culosis, has  a  slight  food  value  (as  a  tissue  sparer) ;  it  may,  when  properly 
given,  stimulate  the  appetite  and  lessen  the  cough,  but  exerts  no  action 
upon  the  disease  itself.  Harris,  who  gave  twenty-six  patients  1^  oz. 
alcohol  every  four  hours,  night  and  day,  for  some  time,  saw  no  extension 
of  the  disease.  Mircoli,  confirmed  by  Gervino,  asserted  that  in  moderate 
quantities  it  neutralizes  the  tuberculous  toxin,  and  so  helps  pulmonary 
tuberculosis.  Meltzer  holds  alcohol  to  be  of  benefit  in  acute  infections, 
producing  by  its  vasoconstricting  action  upon  the  splanchnic  area  a 
redistribution  of  the  blood.  Many  have  thought  that,  as  alcohol  pro- 
duced cirrhosis  of  the  liver  and  of  the  kidney,  it  would  also  produce  it 
in  the  lung,  but  no  good  evidence  of  this  has  been  adduced. 

The  advocates  of  alcohol  in  pulmonary  tuberculosis  have,  however, 
always  based  their  claim  for  it  on  its  symptomatic  effect.  Brehmer  based 
his  warm  support  of  alcohol  on  its  power,  as  he  had  observed  it,  to 
increase  the  appetite  and  to  lower  the  fever.  Other  observers  claim  it 
increases  the  gastric  secretion,  enaljles  more  fatty  food  to  be  taken  and 


"FALSE   SPECIFICS"  579 

assimilated,  stimulates  the  heart  and  central  nervous  system,  preventing 
hypochondria,  relieves  night  sweats  and  insomnia,  and  in  some  cases  les- 
sens coughing.  The  modern  tendency  is  to  reduce  greatly  the  dose 
earlier  advocated  by  Brehmer,  Dettweiler,  Flint,  etc. 

The  objections  to  its  use  are  numerous,  and  more  patients  with  pul- 
monary tuljerculosis  have  been  harmed  than  helped  by  alcohol.  It  is 
nothing  short  of  criminal  to  send  a  young  man  away  from  home  with  his 
trunk  full  of  whisky  bottles,  and  tell  him  to  drink  all  he  can.  The 
enforced  idleness,  the  honne  camaraderie,  prove  too  much  for  many  who 
have  been  warned  against  it,  and  great  care  should  be  exercised  about 
sending  patients  to  a  hotel  for  a  long  residence.  Xot  only  the  men  have 
to  be  considered,  but,  unfortunatel}',  some  classes  of  women  are  not 
wholly  exempt  from  this  danger,  and  Oliver  has  noted  alcoholic  neuritis 
most  frequent  in  pulmonary  tuberculosis.  When  a  patient  once  begins 
to  drink  at  a  healtli  resort,  his  only  salvation  lies  in  turning  his  back 
upon  his  boon  companions  and  seeking  health  elsewhere. 

Alcohol  should  not  be  used  for  some  time  after  hemoptysis,  and  es- 
pecial care  should  be  taken  when  it  is  used  in  cold  climates  and  higli 
elevations,  though  in  the  Alps  it  is  widely  used  without  any  apparent 
deleterious  effect.  Nervous,  excitable  patients  should  avoid  it,  and  indi- 
viduals long  accustomed  to  its  use  in  large  quantities  should  reduce 
this  amount  to  a  minimum.  When  this  is  not  possible,  it  should  be 
proscribed,  as  is  also  the  case  when  it  increases  cough  or  irritates  the 
larynx  or  stomach. 

In  brief,  alcohol  may  be  said  to  be  a  dangerous  food  and  a  "  symp- 
tomatic "  drug  of  considerable  potential  danger,  but  of  value  in  some 
cases  of  pulmonary  tuberculosis.  A  cocktail,  tablespoonful  of  whisky, 
a  glass  of  stout,  of  bitter  ale,  or  of  a  good  wine,  taken  before,  or,  better, 
with  the  first  part  of  the  meal,  may  aid  a  flagging  appetite  or  a  weak 
digestion.  It  must  be  remembered,  however,  that  these  are  to  be  looked 
upon  as  drugs,  and  taken  only  when  necessary.  When  it  is  impossible 
for  a  patient  to  take  milk  without  a  small  amount  of  brandy  or  whisky, 
or  eggs  without  sherry,  these  should  be  allowed.  Insomnia  may  be  re- 
lieved by  a  glass  of  beer  or  ale  or  a  little  whisky  at  bedtime,  but  these 
are  dangerous  remedies.  Brandy  and  champagne  are  of  value  in  some 
cases  late  in  the  disease.  The  judicious  though  rather  free  use  of  spirits 
does  unquestionably  prolong  the  existence  of  a  few  patients  with  slowly 
progressing  chronic  disease. 

Alcohol,  on  the  whole,  is  not  necessary  in  the  treatment  of  pulmonary 
tuberculosis,  as  in  nearly  every  instance  the  same  effect  can  be  produced 
more  surely,  even  if  less  pleasantly,  by  some  other  drug. 

Drugs  that  Produce  Leucocytosis. — Recent  work  upon  the  importance 
of  leucocvtosis  in  tul)erciilosis  has  Ijrought  again  to  attention  a  number 


580  SPECIFIC   TREATMENT 

of  substances  wliicli  cause  leucocytosis.  Tlie  effects  of  tuberculin  are 
discussed  in  another  place.  The  most  important  of  these  substances  are 
nuclein  and  cinnamic  acids. 

Nucleic  Acid. — Nucleic  acid,  which  is  contained  in  tuberculin,  is 
probably  the  best  example  of  this  class  of  drugs.  Its  use  in  the  form  of 
yeast,  which  is  rich  in  nuclein,  has  recently  been  advocated  by  Ullmann, 
Huggard,  and  Morland  ('05).  Long  an  old-fashioned  household  rem- 
edy for  boils,  it  has  recently  been  said  to  be  of  value  in  pulmonary 
tuberculosis,  where  it  increases  the  leucocytes  and  the  opsonic  index 
when  administered  by  mouth  in  doses  of  3  to  10  grams  (50  to  150 
grains)  of  dried  yeast  in  milk  twice  a  day.  Brewer's  yeast  may  be  used. 
It  exerts  apparently  no  effect  upon  the  temperature,  the  kidneys,  or  in- 
tercurrent affections. 

Cinnamic  Acid. — Cinnamic  acid  and  its  sodium  salt,  hetol,  first  ad- 
vocated by  Landerer  ('98-'01),  has  been  used  chiefly  in  Germany. 
When  properly  administered,  hetol  is  said  to  produce  leucocyto'sis  and 
an  increase  of  connective  tissue  about  the  tuberculous  focus.  Others 
have  claimed  that  it  prevents  or  replaces  caseous  matter  by  vascular  con- 
nective tissue,  forming  true  cicatrices,  increases  the  lymph  flow,  the  alex- 
ines,  and  thus  produces  healing  of  the  tuberculous  lesion.  Balsam  of 
Peru,  first  employed  by  Sayre,  of  New  York,  led  Landerer  to  the 
use  of  hetol.  It  has  been  administered  by  ingestion,  by  inhalation,  by 
subcutaneous  injection,  but  preferably  by  intravenous  or  intramuscular 
(intragluteal)  injection.  At  first  a  dose  of  0.05  to  0.1  c.c.  (HI  1^)  of 
a  1-per-cent  solution  of  hetol  (j  to  1  mgm.)  in  0.75  per  cent  NaCl  solu- 
tion is  injected  into  the  brachial  vein  twice  or  thrice  a  week,  and  slowly 
increased  up  to  8  to  15  mgm.  (^  to  ^  gr.)  for  men,  and  5  to  10  mgm. 
(tV  to  I  gr.)  for  women,  which  dose  is  usually  reached  in  three  to  five 
weeks.  The  "  normal  "  dose  is  that  Avhich  produces  no  untoward  symp- 
toms, but  improvement  of  general  and  local  symptoms.  The  rules  for 
increasing  the  doses  demand  the  same  careful  clinical  observation  and 
caution  detailed  for  tuberculin.  The  treatment  is  continued  for  three 
months  in  early,  six  months  in  advanced,  stages.  After  an  interval  of 
four  to  eight  weeks,  a  second  course  of  one  to  two  months  is  advised  if 
tubercle  bacilli  are  still  present.  The  treatment  should  be  continued 
four  weeks  after  the  disappearance  of  tubercle  bacilli. 

The  results  of  tliis  treatment  are,  in  the  hands  of  most  observers, 
favorable.  C'antorowitz  and  R.  Weissmann,  in  Schmidt's  "  Jahrbiicher  " 
('01  and  '04),  have  collected  140  papers  on  the  subject,  a  large  ma- 
jority being  favorable.  Among  28  papers  by  different  observers,  4  noted 
improvement  in  the  tuberculous  condition,  9  in  the  symptoms,  7  were 
doubtful  as  to  the  results,  and  8  were  unfavoral)le  (Brown).  The  same 
division  of  opinion  exists  in  regard  to  experimental  tuberculosis  (in  rab- 


"FALSE   SPECIFICS"  581 

bits  and  guinea  pigs).  Repeated  injection  into  the  same  vein  is  not 
harmful,  and  the  kidneys  are  not  affected,  but  clironic  albuminuria  and 
diabetes  are  contraindications.  Evidently  much  in  regard  to  results 
depends  upon  the  selection  of  early  stages  for  treatment,  and  patients 
with  fever,  hemoptysis,  and  night  sweats  are  not  deemed  suitable.  Am- 
bulatory patients  and  those  discharged  "  prematurely  "  from  sanatoriums 
give  good  results,  and,  according  to  Landerer,  need  no  change  of  resi- 
dence. Landerer  obtained,  in  patients  with  uncomplicated  pulmonary 
tuberculosis,  healing  in  85  per  cent  and  improvement  in  5  per  cent.  In 
all  classes  of  patients  he  obtained  70  per  cent  of  "  good  results." 

For  febrile  patients  he  advises  colloid  silver,  and  for  patients  with 
cavitation  thoracoplasty.  Calcium  chloride  and  sodium  silicate,  in  hope 
of  their  deposition  in  the  scar  tissue,  have  been  injudiciously  advised. 
The  so-called  "  Hoff's  cure,"  consisting  of  cinnamic  acid,  arsenic,  and 
alcohol,  is  administered  per  os,  and  is  now  little  used,  either  by  the 
laity  or  by  the  profession.  Loew  advocated  theoretically  sodium  phenyl- 
propyl  ic  acid,  as  it  contained  less  hydrogen,  and  was,  therefore^,  more 
"  strongly  bactericidal."  Bulling  has  used  it  as  a  spray,  and  obtained 
good  results. 

Ichthyol. — Ichthyol,  first  used  in  pulmonary  tul)erculosis  by  M.  Cohn 
('96),  is  held  to  possess  a  nonirritating,  nonpoisonous,  alterative  action 
(checking  albuminous  decomposition),  as  well  as  tonic  and  vasocon- 
stricting  properties.  It  is  said  to  increase  the  appetite,  to  loosen  and 
reduce  the  expectoration,  to  bronze  the  skin  in  some  patients  (10  per 
cent),  and  to  be  valuable  in  all  patients  through  its  vasoconstricting,  de- 
congesting  action  on  the  lungs.  A  few  observers  have  ol)tained  good 
results.  The  ammonium  sulphoichthyolate,  in  doses  of  2  to  50  drops 
in  water,  capsules  or  pills,  and  ichthoform  (ichthyol  and  formalin),  in 
doses  of  gr.  1|  to  5  (0.05  to  0.3  gm.)  five  or  six  times  a  day;  ichthalbin, 
10  to  15  gr.  (0.6  to  1  gm.)  p.  c,  a  tasteless  powder,  consisting  of  ichthyol 
and  albumin,  are  usually  given  for  some  months.  Ichtliyol  contains 
much  sulphur,  and  has  such  a  disagreeable  taste  and  odor  that  it  is  little 
used.  "Resorption  pills"  (ichtiiyol  and  salicylic  acid)  have  been  tried 
( Rohden ) .     Sulphur  has  for  many  centuries  been  used  as  an  inhalation. 

lodin. — The  antiseptic  action  of  iodin  on  the  tubercle  bacillus  is 
slight  (0.5-per-cent  solution,  after  exposure  of  one  hour,  prevents 
growth,  Xinneman).  It  is  said  to  excite  phagocytosis.  Potassium 
iodid  (gr.  5  to  10),  hydriodic  acid,  and  iodopin  may  aid  the  cough,  but 
the  chief  value  at  present  of  iodin  in  jmlinonary  tiflierculosis  is  as  a 
rubefacient  in  pleurisy.  Iodin  may  be  painted  on  (tincture,  colorless), 
or  rubbed  into  tlie  skin  (iodin  ])etrogen,  10  ])er  cent,  euro])hon  in  olive 
oil,  etc.).  Iodoform,  without  action  in  ])ulinonarv  tul)er(uh)sis,  has  been 
used  intravenously    (Dewar).     Many  coniMuatiuus  of   iodin  and  iodo- 


582  SPECIFIC  TREATMENT 

form  have  been  employed  (eigon,  iodolen,  iodal,  aristol,  nosophen, 
antinosin,  eudoxin,  losophan,  europhen,  loretin,  vioform)  for  one  pur- 
pose or  another  in  tubercailous  patients.  Cantacuzene  ('05)  has  recently 
found  that  defatted  tubercle  bacilli  treated  with  iodin  (Lugol's  solu- 
tion) are  absorbed  much  more  readily,  and  apparently  give  better 
immunity  to  the  animals  experimented  on,  than  tubercle  bacilli  not 
treated  with  iodin.  He  has  also  found  that  the  administration  of 
potassium  iodid  favors  the  absorption  of  these  bacilli  and  of  tubercu- 
lous deposits. 

Silver. — The  chief  benefit  now  attributed  to  the  use  of  silver  is  its 
effect  upon  the  secondary  organisms  in  the  lungs.  In  the  form  of  col- 
largol  it  has  been  given  per  os,  per  rectum,  and  intravenously.  The  re- 
sults have  not  been  very  satisfactory.  Mays  ('00),  who  asserts  that 
pulmonary  tuberculosis  is  fundamentally  a  nervous  disease,  injects 
nitrate  of  silver  under  the  skin  of  the  neck  over  the  vagus.  Protargol 
and  lysargin  have  been  used. 

Lecithin. — Tuberculous  guinea  pigs  are  said  to  live  longer  when 
given  lecithin  (Claude,  '01),  which  in  man  is  asserted  to  be  harmless, 
to  decrease  phosphorus  output,  to  increase  nitrogen  absorption,  weight, 
strength,  and  acidity  of  the  urine,  and  to  be  of  marked  value  in  nervous 
conditions.  It  can  be  obtained  in  i)il]s  or  powder  (dose  0.25  to  0.50  gm., 
3  to  7^  gr.,  per  day),  or  be  given  subcutaneously  in  oil  (dose  0.05  to  0.15 
every  two  days,  or  smaller  doses  more  often.  In  nervous  complications 
(neurasthenia,  etc.)  it  may  be  tried.  Biosin,  an  albumin-iron-lecithin 
combination,  and  glidin  have  been  used. 

Calcium. — Various  salts  of  calcium,  carbonate,  bicarbonate,  phos- 
phate, iodid,  given  by  mouth  or  hypodermically,  alone  or  in  combina- 
tion with  creosote,  tuberculin,  etc.,  are  of  value  on  account  of  the  de- 
mineralization  occurring  in  ])ulmonary  tuberculosis,  but  exert  no  specific 
action.  They  are  said  to  be  deposited  in  the  foci  of  inflammation,  and 
so  afford  a  mechanical  stimulus  which  starts  and  aids  the  process  of 
repair   (Michelaozzi,  '04). 

Cellotropin  (Kopp,  '04),  a  monobenzoylarbutin,  a  white,  odorless, 
slightly  bitter,  cry.stalline  powder,  easily  soluble  in  alcohol,  with  diffi- 
culty in  water,  has  been  suggested  by  Kopp,  for  he  believes,  after  ab- 
sorption unchanged  into  the  blood,  it  stimulates  the  glands  to  increased 
enzyme  formation,  and  thus  forms  "  under  the  influence  of  the  bacillus 
alexines."  The  substance,  in  doses  of  15  gr.  (1  gm.)  three  to  five  times 
a  day,  produces  no  gastric  disturbances,  and  is  suitable  in  not  too  far 
advanced  stages,  where  it  exerts  a  specific  action.  Further  confirmation 
of  the  few  published  results  are  needed  before  it  can  be  recommended. 

Harper  ('01),  basing  his  theory  upon  the  antagonism  of  gout  and 
tuberculosis,  advocated*  the  use  of  urea  (synthetic)  in  doses  of  15  gr. 


"FALSE   SPECIFICS"  583 

(1  gm.)  pro  die,  increased  in  some  cases  to  60  gr.  (-i  gm.)  as  a  maxi- 
mum. Many  observers  have  used  it  without  any  beneficial  effect.  The 
Calcutta  Zoological  Garden  receives  three  hundred  dollars  annually  from 
the  natives  for  the  urine  of  the  rhinocerus,  which  is  taken  for  lung 
disease. 

Griserin  (Kiister,  '04),  first  presented  to  the  profession  under  the 
name  of  "  loretin  "  as  a  substitute  for  iodoform,  is  of  no  value  and  of 
some  danger  in  pulmonary  tuberculosis. 

Basing  his  views  on  the  results  of  Bier's  treatment  in  tuberculous 
joints,  as  well  as  upon  the  "  immunity "  in  heart  disease,  pregnancy, 
and  gibbus,  H.  Weber  ('08)  attempts  to  explain  the  value  of  the  prone 
position  and  the  sanatorium  treatment  in  pulmonary  tuberculosis 
by  the  increased  amount  of  COo  in  the  lungs  and  body,  and  claims 
to  have  had  excellent  results  in  this  disease  by  the  use  of  sodium 
bicarbonate  (4  gm.  a.  c.)  or  levulose  (50  to  100  gm.  daily  for  a 
month)  per  os,  or  the  subcutaneous  injection  of  liquid  paraffin  (an- 
tiphthisin). 

Strychnin. — Strychnin  (gr.  gV,  0.002  gm.)  is  of  value.  It  acts  ad- 
vantageously upon  the  lowered  blood  tension,  a  weakened  heart,  a  jaded 
appetite,  and  upon  the  neurasthenia,  but  is  no  "  specific." 

Inhalations. — Xo  substance  has  3'et  been  found  (nor  will  there  be) 
that  acts  only  on  the  diseased  part  of  the  lung  even  were  it  able  to  pene- 
trate to  the  often  inijjermeable  or  closed  focus  of  disease.  Inhalations 
have  been  used  in  the  treatment  of  pulmonary  tuberculosis  since  remote 
antiquity.  The  substances  used  have  differed  as  widely  as  the  effluvia 
of  cow  stables  and  aromatic  oils  on  one  hand,  and  chloroform  and  hydro- 
fluoric acid  on  the  other.  These  substances  have  been  in  the  form  of 
gas,  spray,  fluid,  and  powder,  varying  from  the  most  innocuous  to  ir- 
ritant, irrespirable  substances  (bromin,  iodin,  and  chlorin).  The 
object  aimed  at  in  most  cases  has  been  a  direct  action  upon  the  tubercle 
bacillus.  The  nose,  tongue,  pharynx  (at  right  angles  to  the  entering 
vapor  or  spray),  the  lar}Tix,  and  the  innumerable  branchings  of  the 
bronchi,  all  offer  in  some  instances  (powders,  coarse  sprays)  insuperable 
obstacles.  The  secretions  upon  the  surface  of  the  air  passages  may  be 
coagulated  by,  or  may  absorb,  the  inhalant.  Notwithstanding  all  this, 
however,  there  finally  remains  the  fact  that  the  diseased  areas  are  often 
impermeal)lc,  and  if  permeable  the  lesion  may  still  be  closed.  Further- 
more, the  failure  of  sprays  to  affect  diphtheria  or  lupus,  both  so  situated 
that  they  are  ready  of  access,  is  well  knouTi.  From  these  facts,  it  is 
readily  seen  that  no  "  specific "  introduced  by  inhalation,  and  acting 
directly  upon  the  focus  of  disease,  can  be  hoped  for. 

The  hemoglobin  absorbs  all  the  oxygen  it  can  hold  in  combination 
from  the  air,  and  superoxygenated  gases  increase  only  the  oxygen  in 


584  SPECIFIC  TREATMENT 

the  serum  (j^  to  j\) .  Oxygen  in  itself  lias  no  specific  effect.  Ozone 
is  an  indicator  of  pure  fresh  air,  and  many  iiave  transferred  the  effect 
of  the  latter  to  the  former,  which  in  reality  is  an  irritant  to  the  respir- 
atory membranes,  and  more  injurioi;s  if  absorbed.  Any  gas  poor  in 
oxygen  causes  reflexly  deeper  respiration,  and  consequently  an  increased 
blood  flow,  which  may  result  in  loosening,  and  even  in  lessening,  the 
sputum  in  some  cases.  This,  no  doul)t,  is  the  explanation  of  the  results 
wlien  any  are  obtained  from  the  use  of  nitrogen,  carbon  dioxide,  and 
sulphuretted  hydrogen  as  inhalations.  Inhalations  of  liydrocyanic  acid, 
chlorin,  bromin,  iodin,  hydrofluoric  acid,-  sulphuric  acid,  osmic  acid, 
nitrous  oxide,  benzene,  anilin,  belladonna,  and  hemlock  leaves  have 
yielded  no  help,  and  possibly  in  some  cases  done  harm. 

Inhalations  of  formaldehyde  and  its  derivatives  (igazol,  mentho- 
bromo-formol,  etc.)  alone  or  in  combination  with  sulphurous  ether, 
chloroform,  mentbol,  etc.,  may  exert  some  influence  upon  secondary  in- 
fection, but  can  also  cause  pulmonary  edema  if  too  strong.  Creosote 
and  the  ethereal  oils  have  been  much  vaunted. 

From  the  fact  tliat  workers  in  and  dwellers  about  cellulose  factories 
seldom  contract  jjulmonary  tuberculosis,  and  do  well  when  this  occurs, 
Hartmann  ('92)  was  led  to  suggest  the  inhalation  of  ligno-sulphite,  pro- 
duced by  the  action  of  sulphuric  acid  upon  the  etiiereal  oil  of  fir,  juniper, 
or  eucalyptus.  It  seems  to  attack  the  mucin,  and  so  loosens  the  ex- 
pectoration. It  is  now  little  used.  Similar  arguments  have  been  ad- 
vanced for  sulphurous-acid  inhalation. 

Sanosin  (Danelius  and  Sommerbrod),  a  mixture  of  charcoal,  sul- 
phur, and  leaves  of  a  variety  of  the  eucalyptus,  for  inhalation  after 
vaporization,  is  of  no  value. 

Sprays. — A  number  of  substances  previously  mentioned  have  been 
used  in  this  manner.  The  inhalation  of  spray  containing  yeast  has  been 
suggested.  The  same  objections  hold  for  sprays  as  for  inhalations,  but 
many  "specifics"  have  been  so  administered. 

Injections. — Inasmuch  as  a  large  number  of  substances  have  been 
injected  in  one  way  or  another  into  the  body,  usually  in  the  vain  hope 
of  finding  a  specific  similar  to  mercury  for  lues,  or  quinin  for  malaria 
and  further,  as  most  of  these  do  not  merit  a  separate  notice,  it  has  been 
deemed  wise  to  collect  many  of  them  under  this  head.  The  number  of 
substances,  soluble  and  insoluble,  that  have  been  injected  into  the  body 
is  extraordinary;  the  fertility  of  imagination  exercised  in  their  selection 
and  the  lack  of  ingenuity  in  controlling  the  results  is  astounding.  These 
substances  have  been  injected  per  rectum,  subcutaneously,  intravenously, 
intratracheally,  and  into  the  pulmonary  tissue. 

A  partial  list  is  appended  (the  substances  in  italics  may  be  of  some 
value,  the  remainder  cannot  be  recommended)  : 


ADDENDA  585 

Per  Eectiim :  Cod-liver  oil,  creosote,  arsenious  acid,  H.S  and  CO,,  etc. 

Subcutaneously :  Cod-liver  oil  (glycerin  extract,  olive  oil,  camphor- 
ated oil  (in  late  stages),  vaselin,  creosote,  guaiacol  (simple,  cacodylate, 
iodoformized),  eucalyptol,  arsenious  acid,  arseniate  of  strychnin,  of  soda, 
sodium  cacodylate,  phosphate  of  lime  (to  replace  excess  lost),  green 
ammonio  citrate  of  iron,  kalodal  (soluble  albuminate  of  silver,  for  nour- 
ishment), AgXOg  (over  vagus),  phenol,  salol,  aristol,  ether  and  opium, 
iodin  with  potassium  iodid,  etc.;  chloride  of  gold,  antiphthisicum 
(liquid  paraffin),  gomenol,  glolnilin,  yeast. 

Intravenously :  Hetol,  formaldehyde,  iodoform,  creosote,  etc. 

Intratracheal:  Creosote,  guaiacol,  menthol,  camphor,  chlorotone,  iodo- 
form, potassium  permanganate,  izal,  eucalyptol,  gomenol,  gobional,  silver 
nitrate  in  olive  oil,  glycerin  or  water,  through  larynx  or  through  skin, 
etc.;  orthoform. 

Intrapulmonary :  Zinc  chlorid,  phenol,  naphthol,  iodoform,  creosote, 
thymol,  iodoformized  glycerin. 

The  intravenous  injection  of  formaldehyde  (50  c.c.  of  a  0.5-per-cent 
solution  in  physiologic  saline  solution),  advocated  by  Maguire,  has  been 
little  used,  and  cannot  be  recommended. 

Intratracheal  injection,  first  used  by  Green  of  Xew  York  ('55),  has 
not  been  very  extensively  employed. 

Jacob's  method  of  pulmonary  infusion  of  tuberculin  and  creosote 
in  large  quantities  has  met  with  severe  and  just  criticism  on  account 
of  its  danger.  Among  the  many  substances  suggested,  the  most  widely 
used  are  menthol,  camphor,  creosote,  and  guaiacol,  alone  or  in  combina- 
tion in  one-to-four-per-cent  solution  in  olive  oil.  The  chief,  if  not  the 
only,  value  of  intratracheal  injections  is  to  control  the  cough. 


ADDENDA 

Summary  of  Specific   Treatment  Presented  at   the  International  Con- 
gress, Held  in  Washington,  D.  C. 

Tuberculinum  purum  is  a  form  of  toxin  prepared  by  Gabrilowitsch 
from  cultures  of  tubercle  bacilli  (human  strain),  and  so  altered  by 
chemical  reagents  that  it  no  longer  produces  any  general  reaction.  The 
initial  dose  is  0.01  mgm.,  the  final  dose  from  100  to  '^00  mgm.  In  80 
per  cent  of  25  patients  (8  with  severe  type  of  the  disease,  and  only  3 
with  a  mild  type)  the  number  of  injections  was  twenty,  extending  over 
forty  to  sixty  days.  The  results  clainunl  l)y  Gal)rilowitsch  are  excellent, 
but  verification  in  the  hands  of  others  has  not  yet  been  made  public, 
and  the  results  are  almost  too  favorable,  though  details  about  the  class 
39 


586  SPECIFIC  TREATMENT 

of  patients  have  not  3'et  been  puljlished.  All  patients,  the  author  thinks, 
may  derive  benefit  from  this  tuberculin. 

Calmette  described  a  new  form  of  tuberculin,  C.  L.,  obtained  by 
centrifuging  in  vacuo  at  a  low  temperature  entire  cultures  of  bovine 
bacilli.  The  product  is  then  filtered,  precipitated  three  times  with  alco- 
hol and  ether,  redissolved  in  water,  and  dialyzed  until  all  the  salts  and 
precipitants  have  been  completely  eliminated.  The  colloid  substances  in 
the  dialyzer  are  precipitated  once  more  by  alcohol  and  ether,  and  dried 
m  vacuo.  The  active  substance  is  not  heated,  and  subjected  to  no  treat- 
ment except  precipitation  by  alcohol  and  ether.  By  von  Lingelsheim's 
method  it  was  found  ten  times  as  toxic  for  guinea  pigs  as  0.  T.,  but 
could  be  introduced  intravenously  into  tlie  body  of  an  animal  in  large 
doses  without  producing  any  elevation  of  temperature.  The  beginning 
dose  is  0.001  mgm.,  which  should  be  slowly  increased  at  intervals  of  ten 
to  twelve  days  in  order  to  avoid  a  reaction  of  more  than  0.5°  C.  This 
tuberculin,  Calmette  believes,  does  not  cure  tuberculosis  any  more  than 
any  other  form  of  tuberculin,  but  delays  the  progress  of  the  disease  and 
endows  the  organism  with  resistance  to  infection,  which  he  and  Guerin 
have  proved  on  cattle.  They,  however,  do  not  acquire  a  true  immunity, 
and,  although  they  do  not  react  to  tuljerculin,  they  are  nevertheless  car- 
riers of  tubercle  bacilli,  and  capable  of  contracting  a  chronic  form  of 
tuberculosis.  Such  results  lead  them  to  oppose  the  use  of  living  tubercle 
bacilli  in  man,  especially  as  tuberculin  is  equally  efficient  and  less  dan- 
gerous. 

Calmette  also  stated  that  tuberculin  possesses  an  affinity  for  lipoids 
(probably  identical  with  lecithin),  which  are  almost  constantly  present 
in  the  serum  of  tuberculous  men  and  cattle.  Arguing  from  the  fact 
that  cobravenin  is  rendered  active  by  the  free  lecithin  of  serum,  he  be- 
lieves that  tuberculin  is  indicated  for  determining  the  affinity  of  the 
patient's  serum  for  the  secretory  products  of  the  tubercle  bacillus.  Its 
systematic  emplo}nnent  enables  the  clinician  to  observe  accurately  the 
effects  of  tuberculin  medication. 

Trudeau  discussed  the  laboratory  (antibacterial)  and  the  clinical 
(antitoxic)  method  of  the  administration  of  tuberculin,  and  stated  that 
the  latter  was  the  better  method.  He  held  that  the  dose  should  be 
slowly  increased,  and  that  he  now  thought  the  size  of  the  final  dose  was 
a  matter  of  less  importance  than  formerly.  The  final  dose  may  be  only 
a  fraction  of  a  milligram. 

Denys  reaffirmed  his  absolute  confidence  in  his  broth  filtrate,  B.  F., 
or  F.  B.,  as  he  calls  it  in  English.  He  advocates  beginning  with  very 
small  doses,  e.  g.,  in  afrebile  patients  with  0.000,000,05  to  0.000,000,1 
c.c,  while  in  even  slightly  febrile  patients  he  advocates  0.000,000,000,5 
to  0.000,000,001  c.c.     He  knows  no  contraindications  to  its  use,  and  at- 


ADDENDA  587 

tributes  its  failure  in  acute  pulmonar}-  tuberculosis  to  lack  of  time  before 
death  ensues.     His  enthusiasm  is  unbounded. 

Hammer  stated  that,  while  tuberculin  would  not  cure  the  most  ad- 
vanced stages  of  pulmonary  tuberculosis,  it  eliminated  many  disagree- 
able symptoms.  In  patients  whose  physical  signs  were  in  Stage  I  or  II, 
or  at  times  even  in  III  (Turban),  recovery  is  to  be  expected. 

Petruschky  reaffirmed  his  belief  in  tuberculin,  both  for  treatment  and 
diagnosis,  and  held  that  patients  with  closed  lesions  should  be  treated 
to  prevent  ulceration  into  the  bronchus  and  the  recurrence  of  tubercle 
bacilli  in  the  sputum. 

Meissen  still  holds  that  tuberculin  has  not  been  proved  to  have  a 
specific  curative  action,  and,  if  used,  should  be  given  only  in  hospitals 
or  institutions. 

The  work  of  Kinghorn,  Twichell,  Carter,  and  Werry,  who  followed 
the  tuberculo-opsonic  index  of  patients  who  were  given  0.  T.  and  B.  E. 
by  the  clinical  method  with  progressing  doses,  showed  that  after  inocu- 
lation this  index  was  raised,  that  positive  and  negative  phases  do  occur; 
that,  when  tuberculin  is  given  at  intervals  of  three  or  four  days,  25 
per  cent  received  the  injections  during  a  negative  phase;  that  in  85  per 
cent  of  these,  the  negative  phase  was  not  accentuated,  but  that  a  positive 
phase  at  once  set  in.  Notwithstanding  the  fact  that  they  believe  that 
this  index  is  of  doubtful  value  in  controlling  tuberculin  injections  on 
phthisical  patients,  and  that  the  aim  of  tuberculin  treatment  should  be 
to  produce  tuberculin  immunization,  rather  than  to  keep  the  opsonic 
index  at  a  high  level — notwithstanding  these  facts,  they  think  the  inter- 
val between  doses  should  be  increased  to  seven  days,  to  allow  the  dis- 
turbance in  the  blood  to  subside.  If  an  abolition  of  the  negative  phase 
be  desirable,  then  this  work  proves  that  intervals  of  three  or  four  days 
are  advisable  for  most  patients. 

Hastings,  who  has  done  much  work  with  the  opsonic  index,  an- 
nounced that  the  variations  "  are  so  wide  without  inoculation,  and  so 
inconstant  after  inoculation,  that  one  cannot  safely  use  the  index  as  a 
guide  for  tuberculin  inoculations." 

The  very  ingenious  work  of  Webb,  \Yilliams,  and  Barber  in  at- 
tempting immunization  by  the  injection  of  increasing  numbers  of  living 
organisms,  beginning  with  one,  is  striking  and  original.  The  technic  of 
Barber  employed,  consists  of  selecting  under  the  microscope  from  a 
hanging  drop  of  emulsion  the  exact  number  of  bacilli  l)y  means  of  a  cap- 
illary pipette.  Such  work,  however,  has  to  do  chiefly  with  the  pro- 
duction of  immunity  in  healtliy  animals,  for  many  experimenters 
(Trudeau,  Calmette,  Courmont,  and  Lesieur)  have  found  that  injection 
of  living  tubercle  bacilli  influenced  a  previous  tuberculosis  little,  if  at  all. 
The  work  of  these  latter  observers  is  certainly  oj^en  to  the  objection  that 


588  SPECIFIC  TREATMENT 

they  used  too  large  doses,  a  point  which  Webb  and  his  confreres  are  now 
endeavoring  to  prove.  They  have,  from  their  reports,  conferred  upon 
mice  immunity  to  anthrax,  and  certainly  upon  guinea  pigs  some  im- 
munity to  tuberculosis.  The  use  of  living  tubercle  bacilli  in  man  is  not 
justifiable  in  the  light  of  our  present  knowledge. 

The  work  of  J.  Courmont  and  Lesieur  throws  some  doubt  upon  the 
immunity  conferred  upon  animals  (cattle,  etc.)  by  some  vaccinations, 
for  they  find  tliat  a  lesion  in  process  of  evolution  prevents  the  evolution 
of  a  second  inoculation,  while  the  first  runs  its  normal  course.  An 
attenuated  tubercle  bacillus,  however,  or  a  strain  little  virulent  for  a 
species  of  animal  may  in  this  way  protect  against  a  second  virulent 
inoculation. 

Flick  reported  the  work  on  Maragliano's  serum  at  the  Phipps  Insti- 
tute. Twenty  members  of  the  staff  used  this  serum,  which  was  prepared 
by  Eavenel  according  to  Maragliano's  methods.  It  was  found  to  have 
no  specific  value,  and  both  cows  wliich  furnished  tlie  serum  were  discov- 
ered to  be  tuberculous,  one  dying  from  generalized  tuberculosis. 

The  untoward  effects  of  Maragliano's  serum  were  studied  in  foriy- 
one  patients  by  Landis,  who  found  evidence  of  marked  hypersuscepti- 
bility  (suffused  face,  dysjmea,  oppression  about  the  heart,  rapid  pulse, 
lumbar  pain,  muscular  tremors,  sense  of  impending  death,  but  no  fatali- 
ties) in  seventeen  per  cent,  who  were  in  a  moderately  or  far  advanced 
stage,  and  confined  to  bed.  Tliere  was  no  definite  time  for  the  occur- 
rence of  these  symptoms.  Amljulant  patients  in  good  condition  did  not 
develop  anaphylaxis. 


CHAPTER   II 

SPECIFIC  THERAPEUTICS  OF  MIXED  AND  COiSTCOMITANT 

INFECTIOXS 

By  GERALD  B.  WEBB 

A  NATURAL  outcome  of  Wright's  exploitation  of  Ijacterial  vaccines  is 
the  application  of  their  use  to  the  concomitant  or  mixed  infections  of 
pulmonary  and  other  forms  of  tuberculosis.  To  attempt  the  cure  of 
cases  complicated  by  secondary  infections  by  means  of  tuberculin  alone, 
trusting  that  the  organism  will  rid  itself  of  these  secondary  invaders, 
is  hardly  rational. 

While  the  suggestion  that  mixed  infections  must  be  expected  in  the 
common  suppurative  processes  which  occur  in  connection  with  surfaces 
which  harbor  microbes  may  well  be  universally  acceptable  as  not  break- 
ing in  on  any  accepted  ideas,  the  suggestion  that  mixed  infection  must 
perforce  be  considered  in  every  case  of  phthisis,  lupus,  tubercular  caries, 
tubercular  cystitis,  and  tubercular  ulceration,  in  the  very  nature  of 
things,  will  be  unacceptable  to  many  clinicians.  Such  a  suggestion  will 
be  felt  to  throw  doubt  not  only  on  the  clearness  of  vision  of  those  who 
have  sought  for  antituberculous  remedies  in  these  diseases,  but  also  on 
the  critical  acumen  of  those  who,  without  taking  into  account  the  falla- 
cies which  are  incidental  to  clinical  methods,  have  confidently  undertaken 
to  pass  final  judgment  on  antituberculous  remedies  by  the  observation  of 
their  clinical  effects  in  cases  in  which,  in  addition  to  the  tubercle  bacillus, 
other  pathogenetic  microbes  may  have  been  at  work. 

Be  it  acceptable  or  unacceptable,  there  is  no  escape  from  the  fact  that 
practically  every  case  of  suppurating  lupus  is  complicated  by  staphylo- 
coccvis  infection,  and  every  aggravated  case  of  lupus  Avith  a  streptococcus 
infection.  What  holds  true  of  lupus,  mutatis  mutandis,  is  true  of 
every  tuberculous  affection  to  which  microbes  can  find  access  (A.  E. 
Wright,  '07). 

At  present  tliere  is  the  greatest  divergence  of  opinion  as  to  tlie  in- 
fluence of  secondary  organisms  on  the  course  of  pulmonary  tuberculosis. 
It  is,  perhaps,  a  fact  that  nuiny  of  these  secondary  organisms  are  of  low 
vitality  and  nonvinilent,  but  it  is  just  as  impossible  for  such  patients 
to  rid  themselves  of  these  as  of  local  infections,  such  as  acne,  furuncu- 

589 


590 


SPECIFIC  THERAPEUTICS  OF   MIXED  INFECTIONS 


losis,  both  such  frequent  afflictions  of  the  tuberculous.  Surgeons  famil- 
iar with  bone  tuberculosis  know  how  well  patients  with  pure  tuberculous 
disease  improve,  and  yet  how  intractable  are  those  cases  with  mixed 
infection. 

The  results  of  Prudden's  ('9i)  well-known  experiments  on  rabbits 
show  conclusively  that  the  concurrent  action  of  two  distinct  pathogenic 
germs  may  result  in  a  considerable  modification  of  the  lesions  which 
either  could  produce  alone. 

It  has  been  well  said  l)y  a  Frenclunan  that  "  the  worst  thing  that 
can  happen  to  a  tuberculous  person  is  to  come  in  contact  with  a  con- 
sumptive," a  renuirk  which  I  would  extend  to  the  greater  danger  the 
tuberculous  invalid  runs  when  exposed  to  an  influenza  epidemic. 

The  suggestion  has  been  made  that  the  influenza  organism  is  prob- 
ably the  means  of  introducing  the  pneumococcus  into  the  system  of  the 
victim  of  pulmonary  tuberculosis,  and  it  is  perhaps  true,  yet  my  own 
observations  would  seem  to  show  that  the  influenza  bacillus  alone  is 
capable  of  much  mischief  in  the  tuberculous  invalid. 

At  the  time  of  writing,  forty-five  patients,  undergoing  inoculations 
with  tuberculin  and  mixed  vaccines,  have  been  exposed  to  a  very  wide- 
spread epidemic  of  a  catarrhal  condition  due  chiefly  to  the  influenza 
bacillus,  in  part  to  the  Micrococcus  caiarrhalis.  Of  these  forty-five  pa- 
tients, five  have  the  influenza  bacillus  persistently  in  the  sputa,  and 
they  have  been  inoculated  periodically  with  their  influenza  vaccines. 
These  have  escaped  "  colds." 

The  results  are  only  suggestive.  They  may  be  tabulated  as  follows — 
forty-five  patients,  exposed  to  a  widespread  influenza  epidemic,  receiving 
inoculations  of  tuberculin  and  mixed  vaccines  every  seven  to  ten  days: 


Inoculated  against  in- 
fluenza with  their  own 
vaccines 

Inoculated  against  in- 
fluenza with  stock 
vaccines 

Preventive  inoculation 
not  given;  patients 
denying  that  they  ever 
had  influenza 


32 


fAll  gave  accurate  his- 
tories of  repeated 
former  attacks.  J 


Escaped  epidemic. 
Escaped  epidemic. 


Fifteen    succumbed    to 
influenza  epidemic. 


Fifteen  of  these  patients,  who  at  the  outbreak  of  the  epidemic  claimed 
never  to  have  had  the  grip — neither  had  the  influenza  bacillus  hith- 
erto been  found — succumbed,  and  the  influenza  bacillus  was  then  found 
in  their  sputa.  Two  of  these  patients,  for  the  first  time,  developed  very 
serious  hemorrhages  within  a  few  days  of  the  infection. 


SPECIFIC  THERAPEUTICS  OF   MIXED  INFECTIONS  591 

Eight  23atients  who  claimed  to  have  had  influenza  frequently  (one 
every  year  for  eight  years)  were  given  from  125,000,000  to  500,000,000  of 
influenza  vaccine  at  each  weekly  inoculation.  These  patients  were  well 
exposed  to  the  epidemic,  and  without  exception  everyone  escaped  infection. 

The  writer  has  ohserved  a  patient's  opsonic  index  to  tubercle  low- 
ered to  O.G  during  an  influenza  attack.  It  is  a  common  observation  that 
patients  with  pulmonary  tuberculosis  may  go  rapidly  down  hill  following 
an  attack  of  influenza,  and  the  writer  would  suggest  that  the  prevention 
of  such  concomitant  infection  should  be  sought  by  the  means  indicated 
above.  The  vaccine  used  in  these  cases  was  prepared  according  to 
Wright's  methods  from  a  case  of  acute  infection  of  a  maxillar}'  sinus 
occurring  in  a  patient  who  had  suffered  a  similar  attack  for  four  or 
more  successive  years.  Heretofore  a  period  of  chronicity  had  followed 
annually,  necessitating  a  specialist's  attention  for  a  period  of  months. 
This  year,  however,  rapid  healing  followed  the  iise  of  the  vaccine. 

The  frequency  of  occurrence  of  the  secondary  invaders  is  listed 
variously  by  different  investigators.  From  an  unpublished  report  from 
Dr.  T.  W.  Hastings,  of  the  Cornell  University  Medical  College,  it  is 
learned  that  in  375  cases  of  nontuberculous  pulmonary  conditions  (tu- 
berculosis suspected,  but  tubercle  bacilli  not  found),  the  frequency  of 
occurrence  of  secondary  organisms  was  as  follows: 

Micrococcus  catarrhalis. 

Pneumococcus  ( Fraenkel ) . 

Streptococcus  pyogenes. 

Staphylococcus  pyogenes  (aureus,  albus,  or  citreus). 

Friedlander's  bacillus   (Bacillus  mucosus  capsulatus). 

Micrococcus  tetragenus. 

Bacillus  influenza. 

Bacillus  subtilis. 

Bacillus  pyocyaneus. 

Cultures  were  taken  in  only  105  of  these  cases,  and  the  same  order 
of  frequency  held,  except  that  staphylococci  were  first  instead  of  fourth. 

Of  156  cases  of  pulmonary  tuberculosis  (tubercle  bacilli  detected  in 
sputum),  cultures  were  taken  in  only  20  cases.  The  order  of  occurrence 
of  secondary  organisms  was  as  follows: 

Streptococcus  pyogenes. 

Micrococcus  catarrhalis. 

Pneumococcus  ( Fraenkel ) . 

Staphylococcus  (aureus,  albus,  or  citreus). 

Bacillus  pyocyaneus. 

Friedlander's  bacillus  (Bacillus  mucosus  capsulatus). 

Micrococcus  tetragenus. 


592 


SPECIFIC  THERAPEUTICS  OF   MIXED  INFECTIONS 


Reference  to  tlie  work  of  Eavenel  and  Irwin  ('07)  shows  results  of 
examination  of  all  the  organs  in  56  cases  that  came  to  the  postmortem 
tahle : 

Bacillus  coli  communis in  40  cases. 

39  " 
30  " 
26  " 
9  " 
11      " 


Streptococcus    

Staphylococcus  pyogenes  albus   . 
Staphylococcus  pyogenes  aureus 

Pneumococcus    

Bacillus  diphtherige   (pseudo)    .  . 
Pyocyaneus,  sarcinae,  etc. 


Examination  of  the  tables  shows  that  our  results  agree  in  the  main 
with  those  of  other  observers.  The  streptococcus,  often  in  chains  or 
pairs,  was  most  frequently  found,  not  only  in  cavities,  but  also  in  the 
organs.  The  notable  exceptions  to  this  were  the  kidneys,  in  which  the 
bacillus  coli  communis  was  found  nineteen  times  and  the  streptococcus 
ten  times  and  the  liver,  in  which  the  bacillus  coli  communis  was  found 
twelve  times,  and  the  streptococcus  only  twice.  The  frequency  with 
which  the  kidney  was  infected  is  worthy  of  comment — twenty-nine  times 
in  the  fifty-six  autopsies — leading  the  liver  in  this  respect.  It  is,  of 
course,  impossible  to  say  in  what  proportion  of  cases  the  bacillary  inva- 
sion was  agonal,  or  postmortem,  but,  in  any  event,  the  liver  \vould  seem 
to  be  more  open  to  such  invasion  than  the  kidneys. 


LUNG  CAVITIES 


Streptococcus. 

37  cases. 

Staphylococcus  pyogenes  albus. 

25     " 

Staphylococcus  pyogenes  aureus 

24     " 

Pneumococcus. 

8     " 

Bacillus  pyocyaneus. 

2     " 

Number    of    cases    examined,    50;  i 

Bacillus  coli  communis. 

37     " 

microorganisms    being   found    in  ( 

Bacillus  lactis  aerogenes. 

3     " 

all. 

Bacillus  diphtheria;  (pseudo). 

9     " 

Sarcinae. 

in    " 

Yeasts. 

12     " 

Spirillum. 

1  case. 

Small  diplococcus  (unidentified). 

2  cases. 

Bacillus  (unidentified). 

6     " 

AREAS  OF   BRONCHOPNEUMONIA 


Streptococcus. 

1  case. 

Staphylococcus  pyogenes 

albus. 

1     " 

Number  of  cases  examined,   5;        / 
microorganisms  found  in  3.              \ 

Staphylococcus  pyogenes 

aureus 

2  cases. 

Pneumococcus. 
Bacillus  diphtherise. 

1  case. 

1     " 

Bacillus  coli  communis. 

1     " 

Unidentified  diplococcus. 

1     " 

PLATE    II 


1. — Shows  ix  the  Same  Field  Pus  Cells  Containing  Tubercle  Bacilli  and  Strepto- 
cocci (Carbol  FrcHsix  and  Methylene-blve). 

2. — Organisms  Similar  to  (1),  but  Contained  in  the  Same  Pus  Cell. 


3. — A  Large  Pus  Cell  Containing  a  Tubercle  Bacillus  and  Many  Staphylococci 
(Carbol  Thionin). 

4. — Pus  Cells  Containing  Staphylococci,  Pneumococci,  and  One  Cell  Containing 
a  Tukercle  Bacillus  and  Pneumococci  (Carbol  Fuchsin  and  Methy'lene-blue). 


r.  MV66. 
.5. — The  Micrococcus  catarrhalis  (not  Taking  Gram's  Stain)  and  the  Pneumococci 
AND  Txtbercle  Bacilli  (Taking  Gram's  Stain>. 
6. — The  Influenza  Bacillus  (Carbol  Thionin). 


SPECIFIC  THERAPEUTICS  OF   MIXED  INFECTIONS  593 

In  lung  cavities,  an  organism  resembling  the  Klebs-Liiffler  bacillus  is 
frequently  found,  and  it  has  been  called  the  "  pseudo-diphtheria  bacillus 
pulmonalis.''  It  is  often  indistinguishable  morphologically  and  culturally 
from  the  true  diphtheria  bacillus,  but  we  have  never  foimd  it  virulent 
for  guinea  pigs.  Some  of  the  cultures  we  have  been  forced  to  regard  as 
true  diphtheria  which  had  lost  its  pathogenic  power. 

Our  studies  have  not  enabled  us  to  draw  any  positive  conclusions, 
though  we  are  convinced  that  in  pulmonary  tuberculosis,  mixed  infections 
play  an  important  part  in  the  production  of  symptoms  and  in  the  course 
of  the  disease. 

Taking  the  staphylococcup  as  being  one  of  the  most  frequently  jires- 
ent  of  the  mixed  invaders,  1  have  grown  numerous  colonies  from  every 
sputum,  from  fift}'  different  patients.  Microscopic  preparations  have 
revealed  it  in  almost  every  case  (Plate  II),  and  it  has  frequently  been 
observed  within  the  pus  cells  in  the  sputum. 

In  infections  (Ricketts,  '06)  the  staph3dococcus  attracts  large  num- 
bers of  leucocytes,  and  the  pus  does  not  coagulate.  The  substance  which 
attracts  leucocytes  is  heat  resistant,  since  killed  cultures  will  cause  ab- 
scesses. In  all  l)ut  the  most  superficial  lesions  a  characteristic  result  of 
infection  is  that  of  cell  necrosis  and  the  liquefaction  of  tissues.  Xeisser 
and  Lipstein  state  tliat  the  necrotizing  substance  is  a  soluble  toxin,  since 
culture  filtrates  cause  marked  necrosis  of  the  internal  organs  (liver, 
lieart,  kidney)  when  injected.  "Hence,  in  staphylomycosis  we  can  dis- 
tinguish two  active  substances  (v.  Lingelsheim,  '08),  the  leucotactic  sub- 
stance in  the  bodies  of  the  cocci,  and  the  more  important  soluble 
staphylotoxin,  which  exercises  not  only  a  local  but  also  a  general  toxic 
action  on  the  body  (Neisser  and  Lipstein). 

The  extensive  necrosis  of  carbuncles  is  an  every-day  observation  pro- 
duced in  an  afebrile  manner  by  the  Stnphylococrnx  pi/ogcnrs.  Tiie 
sputum  from  many  cavity  cases  has  developed,  on  culture,  an  overwhelm- 
ing number  of  Staphylococcus  pyogenes  alhns  or  aureus  colonics,  and 
microscopic  examination  has  shown  staphylococci  as  well  as  di|)hK()cci 
to  1)6  contained  within  the  pus  cells.  With  such  knowledge  of  its  necrotic 
poAvers,  it  would  certainly  seem  just  to  attach  to  this  organism  some  of 
the  blame  for  cavity  formation. 

The  treatment  of  the  mixed  infections  of  pulmonary  and  other  forms 
of  tuberculosis  must  naturally  be  founded  on  the  results  of  investigation  of 
each  individual  case.    This  study  may  be  ap])roached  l)y  three  methods: 

1.  A  carefully  selected  j)ortion  of  sputum  may  be  examined  micro- 
scopically, and  the  various  organisms  may  be  differentiated  by  methods 
of  staining. 

2.  A  ))ortion  taken  from  the  interior  of  the  s|)utuiii  mass  may  be 
planted  out,  and  the  growing  colonies  investigated. 


594  SPECIFIC  THERAPEUTICS  OF   MIXED  INFECTIONS 

3.  The  opsonic  index  of  the  patient  may  be  studied  in  connection 
with  the  different  bacteria  thrown  from  the  sputum. 

The  writer's  plan,  in  one  hundred  cases,  has  been  to  depend  chiefly 
on  the  first  two  methods  of  investigation. 

In  the  first  method  especial  care  has  been  exercised  in  the  examina- 
tion of  the  pus  cells  as  to  their  bacterial  contents,  for  it  is  only  logical 
to  conclude,  since  Wright's  completion  of  Metchnikoff's  theory,  that  the 
bacteria  found  in  the  dead  leucocytes  have  been  actively  campaigning. 

1.  Carefully  selected  portions  taken  from  the  interior  of  sputum 
mass  are  teased  on  three  separate  slides. 

2.  These  slides  are  fixed  by  placing  them  in  a  supersaturated  solu- 
tion of  mercuric  chlorid  for  three  minutes;  then  they  are  washed  with 
water  and. dried. 

3.  One  slide  is  stained  by  the  regular  carbol-fuchsin,  methylene-blue 
method. 

The  second  slide  is  stained  according  to  Gram's  method. 

The  third  slide  is  stained  with  carbol-thienin. 

Eeference  to  the  plates  will  convey  some  of  the  results  of  each  method. 

It  must  not  be  concluded  that  absence  of  bacteria  from  the  pus  cells 
disproves  the  activity  of  organisms  found  on  the  slides,  for  as  the 
phagocytosis  of  the  tubercle  bacillus  is  most  variable,  as  evidenced  by 
sputum  examination,  so  is  the  phagocytosis  of  these  secondary  organ- 
isms; neither  in  such  investigations  is  phagocytosis  of  any  prognostic 
value. 

The  method  of  growing  will  confirm  these  examinations,  and  will 
frequently  produce  organisms  not  observed  by  the  microscope. 

The  technic  of  the  Avriter  has  been  to  tease  out  a  very  carefully 
selected,  small  portion  of  sputum  on  blood  agar  in  Petri  dishes  or  tubes. 
On  this  medium  the  chief  organisms  will  grow  very  rapidly.  The 
Staphylococcus  pyogenes  alhus  (or  aureus)  has  always  been  found,  and 
is  readily  identified.  As  a  general  rule  the  pneumococcus  will  form  a 
green-looking  colony,  and  the  Streptococcus  pyogenes  a  hemolyzing 
colony,  so  that  these  organisms  can  readily  be  picked  out  for  transplanta- 
tion for  vaccine-making. 

The  differentiation  of  the  pneumococcus  from  the  streptococcus  is  by 
no  means  a  simple  task,  and  herein,  probably,  lies  the  reason  that  in- 
vestigators differ  in  their  results  of  frequency.  For  practical  treatment 
this  differentiation  is  not  necessary,  and  the  writer  has  recently  adopted 
the  term  of  pneumostreptococcus  as  an  escape  from  the  difficulty,  a  term 
which  will  include  both  organisms.  A  pneumostreptococcus  has  been 
grown  from  every  case. 

The  third  m^ethod  of  ascertaining  the  activity  of  these  secondary 
bacteria,  testing  the  patient's  resistance  to  them,  as  measured  by  their 


SPECIFIC  THERAPEUTICS  OF    MIXED   INFECTIONS  595 

opsonic  indices,  is  a  laborious  and  unnecessary  procedure.  In  repeated 
instances  patients  have  been  found  with  a  low  index  to  their  own 
staphylococcus  and  pneumococcus,  and  in  febrile  cases  they  have  sho^^^l 
fluctuating  indices  to  these  as  well  as  to  the  tubercle  bacillus. 

Approaching  now,  more  directly,  the  remedial  agents  for  these  in- 
fections, it  has  been  repeatedly  observed  by  Wright  that,  in  the  cure  of 
lupus  and  subcutaneous  tuberculosis,  no  progress  was  made  with  inocu- 
lations or  tuberculin  unless  the  secondary  bacteria  were  removed.  Hence 
the  remarks  contained  in  the  paragraph  quoted  at  the  beginning  of  this 
chapter. 

The  writer  tried  for  weeks  to  improve  a  sycosis  by  inoculations 
of  staphylococcus  vaccine;  an  opsonic  index  to  the  tubercle  bacillus  of 
0.5,  heated  serum  0.3,  later  gave  a  clue  to  a  more  exact  diagnosis  of 
tuberculous  sycosis,  and  the  addition  of  tuberculin  to  the  staphylococcus 
vaccine  soon  produced  a  complete  cure. 

To  those  who  haA'e  watched  the  almost  miraculous  disappearance  of 
boils  following  the  inoculation  of  an  homologous  staphylococcus  vaccine, 
and  who  have  also  seen  a  pneumococcus  pus  pouring  from  an  ear  dis- 
appear entirely  in  a  few  days  through  the  exploitation  of  the  appropriate 
vaccine,  it  will  cause  no  surprise  to  learn  that  comparatively  similar 
results  have  been  obtained  in  the  reduction  of  sputum  of  consumptives 
by  the  application  of  similar  methods. 

It  has  been  the  writer's  lot  to  have  chiefly  had  to  apply  these  methods 
to  patients  with  long-standing  disease,  old  campaigners  who  have  for 
years  tried  every  form  of  treatment.  These  patients,  through  auto- 
inoculations  and  through  the  swallowing  of  their  sputa  ("Wright,  '04),^ 
have  largely  worn  out  their  mechanisms  of  defense,  leaving  little  ma- 
chinery to  place  in  motion. 

Vaccines  have  been  made  from  pure  cultures  derived  from  patients' 
sputa,  according  to  the  technic  of  Wright,  and  inoculations  have  been 
made  at  intervals  of  from  five  to  ten  days.  The  doses,  in  all  cases,  have 
been  small  to  begin  with,  usually  about  20  millions  of  any  vaccine,  and 
the  amount  has  been  increased  to  rarely  more  than  150  millions.  The 
time  of  da}'  preferred  has  been  within  an  hour  or  two  after  meals,  when 
the  receptor  cells  have  presumably  been  occupied  in  the  absorption  of 
nourishment,  and  constitutional  svTnptoms  are  at  such  times  less  likely 
to  follow. 

It  has  been  observed  that  a  very  small  dose  of  tuberculin  inoculated 
into  a  fasting  patient  has  caused  a  reaction,  whereas  the  same  dose  given 

'  Wright  has  shown  considerable  variation  in  the  bactericidal  power  of  serum 
following  on  the  drinking  of  typhoid  vaccine.  His  experiments  are  suggestive,  and 
there  is  a  wide  field  for  investigation  of  the  consequences  of  the  tuberculous  swallow- 
ing their  sputa. 


596  SPECIFIC  THERAPEUTICS  OF   MIXED  INFECTIONS 

several  times  before,  but  following  a  meal,  bad  never  done  so.  Tbis  may 
be  the  reason  wliy  different  degi'ees  of  negative  phase  are  found  by  dif- 
ferent workers.  Perhaps  a  homely  instance  of  toxic  effect  is  the  feeling 
resulting  to  the  unaccustomed  from  smoking  tobacco  before  breakfast. 

The  reader  who  is  familiar  with  Ehrlich's  theory  of  immunity  and 
with  von  Dungern's  ('03)  experiments  in  connection  with  the  immuniza- 
tion of  rabbits  against  the  blood  of  a  particular  variety  of  crab  will 
recognize  that  the  occupation  with  food  of  the  receptors  which  subserve 
the  nutrition  of  the  cell  may  delay  the  incorporation  of  the  toxic  ele- 
ments of  the  vaccine  with  the  cell  protoplasm. 

To  ascertain  if  leucocytes  had  a  preferential  appetite  for  one  organ- 
ism more  than  for  another,  an  experiment  was  undertaken  with  the 
blood  of  a  patient  suffering  from  a  mixed  infection  of  tubercle  and 
staphylococcus,  and  who  received  inoculations  for  both.  The  opsonic 
index  to  each  organism  was  found  to  be  1.2.  The  tubercle  and  staphy- 
lococcus emulsions  were  then  mixed,  and  the  opsonic  indices  again  taken. 
The  mixed  organisms  found  in  the  leucocytes  were  counted,  and  the 
index  to  tubercle  was  found  to  be  1.1,  and  to  staphylococcus  1.2.  These 
results,  practically  identical,  were  confirmed  by  a  second  experiment  with 
another  patient. 

It  would,  therefore,  seem  that,  given  sufficient  opsonin,  the  white- 
blood  corpuscle  is  impartial  in  his  selection  of  foes. 

All  patients  affected  with  chronic  pulmonary  tuberculosis  in  an  ar- 
rested condition  have  been  found  to  have  low  opsonic  indices  to  the 
tubercle  bacillus  as  well  as  to  their  secondary  organisms.  The  condition 
of  such  a  patient  is  best  described  by  comparing  him  to  a  coimtry  mas- 
tered by  the  armed  occu})ation  of  mixed  hosts. 

It  may  be  profitable  to  cite  a  few  illustrative  cases  of  different  types 
of  mixed  infection: 

Case  I. — Mrs.  B.,  age  twenty-six,  sent  to  Colorado  Springs,  Novem- 
ber, 1906,  for  catarrhal  phthisis.  Infiltration  and  sticky  rales  at  apices 
of  both  lungs;  scarcely  any  cough;  no  expectoration;  gradual  gain  in 
general  health  till  February,  1907,  when  she  had  an  attack  of  influenza, 
followed  by  a  cough  and  purulent  expectoration,  with  coarse  rales  at  both 
apices. 

Sputum. — No  tubercle  bacilli ;  pneumocoeci  and  staphylococci,  the 
former  found  frequently  within  the  pus  cells.  The  sputum  was  planted 
out,  and  pneumococcus  and  staphylococcus  colonies  grew,  the  former  out- 
numbering the  latter.  Vaccines  were  made,  as  the  patient  showed  after 
several  weeks  no  ability  to  conquer  her  cough. 

March  10th. — Inoculation  of  20  millions  of  pneumococcus  vaccine. 
Sputum  increased   in   amount  for  several  days,  followed  by  a  decrease. 

March    16th. — Inoculation    of    30    millions   of   pneumococcus   vaccine; 


SPECIFIC  THERAPEUTICS  OF   MIXED   INFECTIONS  597 

bronchial  wheezing  which  had  been  annoying  patient  all  disappeared;  no 
expectoration  for  several  days. 

April  1st. — Rales  at  both  apices  now  again  of  the  sticky  character; 
three  more  inoculations  were  given  with  the  addition  of  some  staphy- 
lococcus vaccine,  and  small  doses  of  Koch's  new  tuberculin. 

October,  1907. — Patient  still  without  cough  or  expectoration.  Sticky 
rales  persist  at  each  apex.  Opsonic  index  to  tubercle  persistently  low; 
inocuhition  of  Koch's  new  tuberculin  started,  as  climatic  help  has  not  i)ro- 
duced  a  complete  cure. 

This  case  would  seem  to  illustrate  the  theory  held  by  some  that  the 
influenza  bacillus  is  necessary  for  the  introduction  of  the  pneumoeoccus. 

Case  II. — May,  1907. — Mr.  G.,  age  forty,  had  pulmonary  tuberculosis 
for  six  years;  cavity  in  each  lung.  For  some  months  past  was  suffering 
from  persistent  fever,  following  an  attack  of  influenza,  accompanied  by 
excessive  expectoration;  sputum  measured  six  ounces.  Extensive  sycosis 
(staphylococcus)  of  mustache  and  hair  in  nostrils,  of  several  years' 
duration. 

Sputum. — Tubercle  bacilli,  pneumostreptococci  and  staphylococci 
present;  some  phagocytosis  of  all.  Cultures  were  made,  and  colonies  of 
Staphylococcus  aureus  predominated.  Inoculations  of  a  staphylococcus 
vaccine  temporarily  increased  the  amount  of  sputum,  soon  followed  hy  a 
decrease  to  less  than  two  ounces. 

The  sycosis,  which  was  assisted  by  epilation  (former  epilation  had 
failed  to  cure),  rapidly  disappeared,  as  also  did  the  patient's  fever.  A 
gain  in  weight  of  over  thirty  pounds  was  made,  and  a  bedridden  patient 
was  restored  to  comparatively  good  health. 

Case  III. — January,  1907. — Miss  D.,  age  forty,  had  pulmonary  tuber- 
culosis eight  years.  Cavity  in  left  apex.  Profuse  expectoration  for  six 
years;  amount  of  sputum  daily,  four  ounces. 

Sputum. — Tubercle  bacilli,  diplococci,  staphylococci,  some  phagocyto- 
sis of  all  shown  by  examination  of  pus  cells.  Cultures  showed  a  few  colo- 
nies of  a  pneumostreptococcus,  enormous  numbers  of  Staphylococcus 
aureus  colonies ;  vaccine  made  of  the  latter. 

Following  the  first  few  inoculations,  the  sputum  was  reduced  to  barely 
half  an  ounce ;  a  clearing  out  of  her  cavity  at  night,  caused  by  recumbent 
posture,  was  completely  stopped,  and  for  the  first  time  in  eight  years  the 
patient  was  able  to  lie  down  and  sleep  through  the  whole  night  undis- 
turbed by  coughing. 

October,  1907. — With  the  exception  of  an  exacerbation  lasting  a  few 
days  this  summer,  the  same  improvement  continues. 

Results  in  Inoculated  Cases 

The  result  in  fifty  cases  inoculated  by  the  author  witli  liomologous 
vaccines  prepared  from  tlie  mixed  organisms  are  best  summed  up  as 
follows : 


598  SPECIFIC  THERAPEUTICS   OF    MIXED   INFECTIONS 

1.  In  no  case  has  a  patient  been  harmed. 

2.  Many  patients  have  had  exacerbations  more  rarel5^ 

3.  Expectoration  in  nearly  all  cases  has  been  lessened;  nocturnal 
coughs  have  frequently  been  eliminated. 

4.  In  some  cases  a  chronic  catarrhal  hoarseness  has  entirely  disap- 
peared. 

5.  Concomitant  pus  affections  have  cleared  away,  such  as  suppura- 
tion of  ears,  staphyloccic  acne,  and  sycosis. 

6.  AVhen  these  vaccines  have  been  combined  with  small  doses  of 
Koch's  new  tuberculin,  spreading  infiltrations  have  been  averted  and 
cleared  up. 

7.  In  a  case  which  displayed  tubercle  bacillus,  streptococcus,  pneu- 
mococcus,  staphylococcus,  and  Micrococcus  catarrhalis,  the  latter  was 
entirely  eliminated  by  appropriate  vaccine,  and  the  amount  of  sputum 
was  reduced  from  four  ounces  to  less  than  one  ounce  daily. 

8.  Evacuations  of  four  to  six  ounces  of  sputum  daily  from  cavities 
have,  in  several  cases,  been  reduced  to  less  than  one  ounce. 

The  impression  h.as  been  gained  that  the  "  bronchorrhea  "  type  of 
cases  has,  perhaps,  received  less  benefit  connected  with  the  reduction  of 
sjnitum  than  the  "  cavernous "  ty])e,  and  a  possil)le  explanation  may, 
perhaps,  be  found  in  the  results  of  inoculations  of  staphylococcus  vac- 
cines for  acne  and  boils.  Owing  to  the  difference  in  the  access  of  blood 
to  the  skin  surface  and  to  the  subcutaneous  tissues,  the  boils  have  been 
found  much  more  amenable  to  increased  opsonic  lymph  than  the  acne 
spots. 

The  experience  of  the  writer  has  been  limited  to  vaccines  made  of 
the  staphylococcus,  streptococcus,  pneumoeoccus,  influenza  jjacillus,  and 
Micrococcus  catarrhalis.  At  the  present  time  a  method  is  under  trial 
which  may  very  materially  simplify  the  making  of  these  vaccines,  and 
also  produce  them  more  potent,  as  a  result  of  lessened  attenuation  from 
transplantation.  The  sputum  is  teased  on  a  slant  of  blood  agar,  which 
is  prepared  from  each  patient.  Colonies  develop  in  approximatel}''  the 
same  proportion  in  which  the  organisms  have  been  active.  These  are 
washed  off  in  salt  solution,  the  emulsion  thorouglily  shaken,  a  slide  pre- 
pared for  enumerating,  and  the  production  is  immersed  in  a  water  bath 
at  60°  C.  for  one  and  a  quarter  hours.  The  vaccine  so  made  is  tested  in 
the  usual  manner,  and,  when  counted,  is  decanted  to  the  required 
dilution. 

This  method  has  been  tried  with  success  in  purulent  ear  and  bladder 
infections,  and  so  far  has  given  excellent  results  in  pulmonary  tuber- 
culosis. It  is  not  so  scientific  nor  so  exact  as  that  of  isolating  each  or- 
ganism. The  count  of  each  organism  in  such  a  mixed  vaccine  is  difficult, 
it  often  being  impossible  to  say  what  is  a  pneumoeoccus  and  what  is  a 


SPECIFIC  THERAPEUTICS  OF   MIXED  INFECTIONS  599 

staphj'lococcus,  yet  an  error  witliin  a  few  millions  is  practically  imma- 
terial in  vaccine  therapy. 

A  lasting  immunity  nmst  not  be  expected  from  inoculations  of  these 
vaccines,  just  as  a  lasting  immunity  to  the  tubercle  bacillus  is  unattain- 
able by  any  tuberculin  administration.  After  the  apparent  maximum 
results  have  been  obtained,  most  patients  have  been  kept  in  touch  by 
inoculations  at  intervals  of  a  few  weeks. 

In  conclusion,  the  author  would  put  forth  the  earnest  plea  that 
these  potent  remedies  be  used  early,  while  the  machinery  of  immuniza- 
tion is  yet  unworn,  and  that  they  be  added  to  the  tuberculin  treatment 
so  well  advocated  by  Trudeau  and  Wright.  Then  the  ranks  of  the  ad- 
vanced tuberculous  will  be  lessened. 


CHAPTER   III 

HYGIENE,    DIET,    AND    OPEN    AIR    IN    THE    TREATMENT 
OF   TUBERCULOSIS 

HOME  TREATMENT  BY  SANATORIUM  METHODS 
By  THOMAS  D.  COLEMAN 

Cases  cared  for  in  the  liome  are  for  the  most  part  omitted  in  statis- 
tics because  most  doctors  do  not  keep  accurate  case  histories,  and  those 
who  do,  do  not  always  report  them  ;  on  the  other  hand,  most  sanatoria 
do  report  their  cases,  and  many  of  tliem  do  not  accept  patients  who  are 
in  advanced  stages  of  the  disease. 

Flick,  Pratt,  and  others  have  shown  how,  witli  a  little  trouble, 
a  small  expenditure  of  money,  and  a  directing  hand,  even  the  slum 
dweller  may  have  his  sanitary  surroundings  improved  and  the  length 
of  his  life  increased.  They  have  recently  been  giving  object  lessons 
in  this  direction  that  are  far  reaching  in  their  influences  for  good. 
They  are  showing  not  only  to  the  laity  but  to  the  profession  the  bene- 
ficial results  that  may  be  obtained  even  in  insanitary  surroundings.  The 
tuberculous  patient  is  being  taught  that  even  in  the  slums  and  tenement- 
house  districts  their  surroundings  may  be  improved ;  they  are  being 
taught  the  value  of  order  and  cleanliness,  of  wholesome  food,  and  the 
necessity  of  fresh  air.     (See  Appendix.) 

Instead  of  living  in  stuffy,  ill-ventilated  quarters  which  the  sun  never 
reaches,  the  patient  is  being  taught  to  use  the  courtyard  of  the  tene- 
ment, in  which  a  tent  may  be  erected,  or  a  balcony  over  which  a  suitable 
awning  may  be  placed  to  protect  it  from  the  inclemencies  of  the  weather ; 
or  even  the  roof  of  the  house  may  be  utilized  for  the  erection  of  a  tent. 
On  sloping  roofs  a  floor  may  be  necessary  with  banisters  around,  but  on 
a  flat  roof  these  may  be  dispensed  with.  These  advantages  may  be  ob- 
tained by  almost  anyone  who  will  take  the  trouble  or  make  the  effort. 
These  accessories  to  the  home  may  often  be  obtained  by  the  expenditure 
of  a  few  dollars.  In  passing  a  palatial  residence  only  recently,  I  had 
impressed  on  me  how,  in  the  essentials,  the  rich  have  little  advantage 
of  the  poor.  The  stone  mansion  was  imposing  in  its  grandeur.  It  occu- 
pied a  large  plot  of  land,  which  was  made  more  beautiful  by  the  land- 
600 


FOOD  601 

scape  gardener's  skill ;  huge  stone  pillars  supported  the  ornate  iron  fence 
that  inclosed  it.  One  could  not  but  envy  the  possessor,  but  a  glance  a 
little  farther  back  made  the  envy  give  place  to  pity — an  unostentatious 
tent  in  the  background,  on  the  lawn,  told  tlie  tale — the  fight  for  life 
was  going  on  not  in  the  mansion,  but  in  the  tent. 

In  presenting  the  detailed  treatment  of  these  cases,  I  have  not  con- 
sidered it  desirable  to  separate  the  sanatorium  from  any  other  intelligent 
routine  treatment,  for  the  reason  that  in  the  homes  of  the  well  to  do 
the  sanatorium  treatment  may  be  equaled,  if  not  surpassed ;  in  the  homes 
of  the  less  wtII  to  do,  even  in  the  houses  of  the  poor,  wdien  the  patient 
cannot  or  will  not  go  to  the  sanatorium,  an  approximation  to  the  ac- 
cepted standards  should  be  made,  as  far  as  the  intelligence  and  ability 
of  the  patient  will  permit. 

FOOD 

Tuberculosis  formerly  was  generally  called  consumption,  because  of 
its  destructive  metamorphosis,  and  in  the  literature  of  medicine  we  still 
find  the  terms  "  galloping  consumption,''  "  quick  consumption,"  etc.  In 
both  acute  and  chronic  tuberculosis  the  subcutaneous  fat  disappears,  the 
muscles  decrease  in  size  and  power.  To  counteract  this  retrograde  tend- 
ency, an  intelligent  direction  of  the  food  is  necessary.  This  direction  not 
only  includes  tiie  quality  and  quantity,  but  its  preparation  as  well. 

It  has  been  determined  by  physiologists  that  a  man  of  average  size, 
doing  ordinary  work,  requires  about  120  gm.  of  albumin,  50  gm.  of  fat, 
500  gm.  of  carbohydrates  daily  in  order  to  replenish  his  bodily  wastes, 
and  he  thrives  best  on  a  mixed  diet.  An  adult  of  average  size  consumes 
about  3,000  calories  of  combustible  material  per  dav,  and  since  albumin 
yields  4.1,  fat  9.3,  and  carbohydrate  4.1,  it  will  be  found  that  the  afore- 
mentioned dietary  contains  approximately  3,000  calories.  A  tuberculous 
patient  requires  even  more  than  this. 

While  this  serves  as  an  index,  it  must  not  be  followed  too  closely, 
since  elements  of  error  creep  in  that  cannot  be  measured  mathematically. 
For  example,  food  constituents  vary  in  composition  in  their  raw  state 
and  in  preparation.  Again,  the  question  of  taste  comes  into  considera- 
tion, and  with  it  problems  of  digestion  and  assimilation,  so  that  we  must 
make  a  liberal  allowance  for  these  factors.  Long  before  Pavloff  chroni- 
cled his  valuable  observations,  we  were  familiar  with  the  expression, 
"  his  mouth  watered  for  food  " — the  physiologic  interpretation  of  which 
is  that  the  smell  or  sight  of  food  excited  the  salivary  glands,  and  thus 
prepared  for  the  digestion  of  food.  We  have  known  for  many  years  that 
the  opposite  holds  true:  giving  unappetizing  food  or  giving  food  to  an 
individual  wbo  is  under  great  mental  stress,  the  food  is  not  only  hard 
to  swallow,  but  difficult  of  digestion  as  well.     Again,  T  have  found  that 


602 


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a  large  percentage  of  my  tuberculous  patients  suffer  from  gastric  catarrh, 
which  not  only  blunts  their  appetites,  but  impairs  their  digestion. 

An  experience  of  two  decades  has  brought  me  to  this  attitude  in 
prognosis :  if,  after  two  or  three  months,  the  patient  can  take  the  amount 
of  food  that  he  requires,  and  -gains  weight  on  it,  my  prognosis  is  influ- 
enced favorably.  In  other  words,  an  engine  is  no  stronger  than  its  boiler, 
and  a  man  than  his  stomach.  I  have  rarely  found  the  tuberculous  process 
to  be  advancing  when  the  patient  has  been  steadily  gaining  weight  for 
any  length  of  time.  Proper  nourishment,  then,  is  of  the  first  importance, 
for  patients  do  well  even  under  adverse  climatic  and  other  conditions, 
but  they  cannot  improve  without  food,  and  an  abundance  of  it.  We 
must  also  introduce  such  aids  to  digestion  as  the  individual  case  may 
require.  Food  values  in  calories  of  energy  have  their  true  place,  and 
hold  good  for  the  healthy  individual,  but  they  often  savor  too  much  of 
the  mechanical  in  those  who  are  sick  and  have  disordered  digestions. 

The  most  reliable  guide  of  the  patient's  improvement  is  liis  gain  in 
weight.  He  should  be  weighed  each  week,  at  the  same  time  of  day  and 
under  the  same  physical  conditions,  and  his  food  consumption  should  be 
regulated  by  the  result.  Tlie  following  table,  from  calculations  made  by 
Boas  and  Cornet,  gives  the  food  values,  in  calories,  in  100  gm.  or 
0.1  liter,  of  the  articles  of  diet  mentioned : 


Milk 67 

Skimmed  milk 40 

Cream 215 

Buttermilk. . .' 41 

Butter 756-807 

Pot  cheese 179 

Swiss  cheese 340 

Scrambled  egg 188 

One  egg 70-80 

Beef,  raw 119 

Beef,  boiled 209 

Beef,  fried 214 

Veal  cutlet,  raw 142 

Veal  cutlet,  fried 230 

Calves'  brain,  raw^ 140 

Sweetbreads 90 

Pork,  fat 313 

Bacon 617-761 

Chicken  (breast),  raw 100 

Tongue 393 

Smoked  meat 255 

Smoked  ham 438 

Pomeranian  goose's  breast 381 

Bologna  sausage 445 

Liver  sausage 290 

Carp,  raw 93 

Pike,  raw 72 

Turbot,  raw 101 

Trout,  raw 106 


Salmon,  raw 133 

Haddock,  raw 61 

Sole,  raw 95 

Perch,  raw 76 

Oysters,  raw 20 

Pickled  herring 246 

Smoked  salmo.n 224 

Kiel  sprats 243 

Caviar 278 

Rice  cooked  in  milk 177 

Mashed  potatoes  with  butter 127 

Spinach,  raw 39 

Spinach,  boiled 166 

Puree  of  beans 193 

Peas 75 

Beans 41 

Asparagus 18 

Farina  pudding 288 

Omlette  soufflee 237 

Noodles  (macaroni) 353 

Raw  sugar 406 

Corn  bread 203-232 

Pumpernickel 229 

Wheat  bread 229-260 

Zwieback 332-358 

Cakes 374 

Corn  brandy 280 

Carrots 41 


FOOD  603 

In  no  other  chronic  disease  is  abundant  feeding  so  essential.  It  must 
be  carried  out,  not  only  through  the  abundance  of  food  furnished,  but 
by  its  quality,  by  its  variety,  by  its  method  of  preparation,  by  digestive 
stimulants  and  aids,  and,  in  special  cases,  by  the  employment  of  the 
stomach  and  rectal  tube.  While  it  is  possible  to  overburden  the  digestive 
tract  of  the  patient,  this  danger  is  insignificant  compared  with  the  like- 
lihood of  not  getting  enough  food  to  make  good  his  wastes,  and  to  fortify 
him  against  the  ravages  of  the  disease.  That  diet  is  best  which  taxes 
the  alimentary  powers  least  and  furnishes  the  greatest  amount  of  nour- 
ishment. 

The  demand  for  an  excess  of  fats  is  in  no  disease  more  pronounced, 
and  was  early  recognized  in  the  emplo}Tnent  of  cod-liver  oil,  under  the 
impression  that  it  was  a  cure  for  tuberculosis.  Milk,  fresh  and  pure, 
or  in  various  modifications,  is  of  greatest  value  in  many  cases.  When 
there  is  hyperacidity,  and  the  milk  forms  large  curds  in  the  stomach,  a 
little  limewater  added  to  it  will  overcome  the  difficulty.  In  other  cases, 
milk  diluted  with  an  equal  part  or  a  third  of  vichy  or  ordinary  carbon- 
ated water  will  be  tolerated  Avhen  plain  milk  will  not.  Similarly,  but- 
termilk is  not  only  more  palatable  to  some,  but  is  more  easily  digested, 
and  koumiss,  matzoon,  and  milk  artificially  fermented  ("  lactobacil- 
line  ")  are  all  varieties  of  milk  to  be  considered  and  recommended  as 
the  case  reqv;ires.  The  patient  should  take  from  one  to  two  quarts  of 
milk  daily,  plain  or  modified,  in  addition  to  other  food. 

Eggs,  in  nutritive  value  and  ease  of  assimilation,  occupy  a  position 
second  only  to  milk,  and  are  sul)jeet  to  a  like  variety  of  preparation. 
The  simplest  form  in  which  the  egg  may  be  administered  is  egg  albumen, 
and  I  have  found  that  not  only  invalid  adults,  but  babies  at  the  breast, 
can  take  this  form  of  nourishment  when  they  can  take  no  other.  The 
way  in  which  I  usually  have  it  prepared  is  to  take  the  white  of  the  egg, 
clip  it  with  scissors  to  keep  it  from  cohering,  add  a  little  crushed  ice, 
orange  juice,  and  a  ])inch  of  sugar.  The  most  delicate  stomach  will  not 
only  tolerate  this,  but  the  patient  will  relish  it.  If  for  any  reason,  par- 
ticularly in  the  case  of  babies  or  patients  suffering  from  intestinal  tuber- 
culosis, the  orange  juice  is  contraindicated,  arrowroot  or  oatmeal  or  bar- 
ley water  may  be  substituted,  and  a  flavoring  extract  or  cognac  brandy 
may  be  added. 

In  the  majority  of  cases  the  whole  egg  is  taken.  At  the  beginning 
a  little  sherry  or  port  wine  in  the  bottom  of  the  glass,  then  the  egg,  and 
on  top  again  the  wine,  making  a  sort  of  "  egg  sandwich,"  may  be  used, 
or  whisky  or  brandy  may  be  so  employed,  but  soon  these  may  be  dis- 
pensed with  and  the  egg  swallowed  without  them.  I  have  had  patients 
take  as  many  as  twelve  eggs  daily.  Again,  patients  may  take  the  eggs 
in  milk,  or  with  the  addition  of  whisky  or  brandy,  making  an  eggnog, 


604      HOME  TREATMENT  BY  SANATORIUM  METHODS 

or  with  sherry  or  port  wine,  making  a  sherry-  or  port-wine  flip.  In  the 
matter  of  cooking,  eggs  may  be  taken  soft  boiled,  shirred,  poached,  or 
scrambled,  or  they  may  even  he  hard  boiled.  Indeed,  they  occupy  a 
place  in  our  dietary  that  is  insufficiently  appreciated.  They  are  used  in 
all  batter  breads,  meringue,  and  cakes. 

Meat  comes  third  in  the  dietary  of  the  tuberculous  patient.  Those 
who  are  robust  take  meat  of  many  kinds  and  variously  prepared.  It 
may  be  stated  generally  that  fried  meat  of  any  kind  is  harder  to  digest 
than  when  prepared  in  any  other  way.  I  think  it  is  true  of  meat  as  of 
milk :  that  it  is  easiest  digested  raw,  so  that  it  will  be  found  that  the 
raw-beef  sandwich  can  be  digested  when  no  other  form  of  solid  food  can. 
The  objections  to  taking  meat  raw  come,  first,  from  our  natural  aver- 
sion, which,  strangely  enough,  does  not  pertain  to  oysters,  clams,  etc., 
and  to  the  parasites  (which  are  destroyed  by  cooking).  Again,  cooking 
makes  the  connective-tissue  portion  of  the  meat  more  digestible. 

ISText  to  this,  and  even  beyond  it  in  certain  asthenic  cases,  is  the 
squeezed-beef  juice,^  and  largely  because  it  may  be  swallowed  without 
mastication. 

In  the  matter  of  meat,  the  flesh  of  any  edible  animal  is  wholesome 
if  properly  seasoned  and  cooked.  In  this  respect  the  taste  of  the  patient 
should  be  consulted  as  far  as  possible,  it  being  borne  in  mind  that  shell- 
fish are  less  nourishing  than  many  lentils,  and  that  pork  and  veal  are 
difficult  of  digestion. 

Prepared  Foods. — Of  the  prepared  foods,  some  are  of  value.  Among 
the  first  may  be  mentioned  the  milk  preparations.  Of  all  of  these  I  may 
say  that,  so  far  as  my  experience  goes,  they  are  makeshifts;  they  may 
aid  in  nutrition,  but  are  insufficient  of  themselves.  The  beef  preparations 
depend  largely  for  their  nutritive  value  on  the  wine  which  they  contain, 
and  Graham  Lusk  has  recently  shown  that  one  of  the  more  popular  of 
these  contains  no  more  nutrition  than  an  equal  quantity  of  milk.  When 
administering  them  in  tablespoonful  doses  they  are  totally  inadequate. 

Alcohol. — It  has  been  proved  that  alcohol,  when  used  to  excess,  not  only 
does  not  protect  the  individual  from  tuberculosis,  as  was  formerly  believed, 
but  absolutely  predisposes  him  to  it.  On  the  other  hand,  Professor  Atwater 
and  others  have  demonstrated  beyond  question  that  alcohol,  in  modera- 
tion, is  a  food  and  beneficial  to  the  system.  This  he  is  able  to  maintain 
not  only  from  his  experiments,  but  from  the  fact  that  there  is  no  hardier 
stock  of  people  to  be  found  on  earth  than  the  wine-drinking  nations. 

1  This  is  made  by  taking  blocks  of  beef  two  inches  square  (round  steak  is  best  for 
this  purpose),  putting  them  into  a  red-hot  skillet,  and  cooking  them  quickly,  turn- 
ing the  while.  They  are  then  gashed  with  a  knife  and  squeezed  with  a  meat  press  or 
lemon  squeezer  into  a  cup  standing  in  hot  water.  This  keeps  the  juice  hot  and 
makes  it  more  palatable. 


FOOD  605 

It  luiR  been  shown  tliat  alcohol  is  a  negative  food;  that,  in  its  im- 
mediate oxidation,  it  saves  tissues  that  would  otherwise  be  expended  in 
life  processes.  In  moderate  amounts  it  stimulates  the  appetite,  improves 
digestion  and  reduces  the  temperature,  and  diminishes  the  night  sweats. 
The  excessive  use  of  alcohol  not  only  fails  to  stimulate,  but  depletes  the 
system ;  the  continuous  use  of  it  also  leads  to  the  habit,  so  that  the  physi- 
cian and  the  patient  must  be  constantly  on  guard.  Alcohol  taken  un- 
wisely may  not  only  destroy  the  appetite,  but  leads  to  poverty,  degrada- 
tion, and  crime.  Wisely  employed,  it  improves  the  appetite,  makes  the 
digestion  better,  and  protects  the  tissues. 

WHienever  the  digestion  will  permit,  an  excess  of  fats  should  be  fur- 
nished ;  e.  g.,  the  fat  of  pork,  mutton,  fowl,  beef,  butter,  cream,  olive  oil, 
fatty  fish  (e.  g.,  Sjianish  mackerel,  poinpano,  eels,  salmon,  shad,  sardines, 
etc.).  For  a  similar  reason,  beans  and  peas  are  to  be  recommended  be- 
cause of  their  liigh  nutritive  value. 

Carbohydrates  are  fat  producers,  and  these  should  be  prescribed  lib- 
erally. Among  these  may  be  mentioned  corn,  wheat,  graham  and  batter 
breads,  pies,  puddings,  and  cakes ;  cane  sugar,  maple  sugar,  and  honey,  all 
admitting  of  various  combinations  and  an  infinite  variety  in  preparation. 

Among  the  proteids,  milk,  eggs,  and  meat  form  the  triumvirate;  all 
may  be  taken  raw,  or  prepared  in  the  more  tempting  ways  known  to  the 
culinary  art. 

Dietaries.— The  following  dietaries  are  applicable  to  the  average  in- 
cipient or  moderately  advanced  case,  it  being  remembered  that  the  indi- 
vidual taste  and  the  state  of  the  digestive  api^aratus  of  the  patient  cannot 
be  disregarded.  It  should  also  be  borne  in  mind  that  not  only  the  time 
of  feeding,  but  the  quality  and  (minimum)  quantity  of  food  must  be 
prescribed  by  the  pliysician : 

Breakfast,  8  a.m. — Fruits;  cereals;  one  raw  egg;  three  glasses  of 

milk ;  coffee ;  toast. 

Breakfast,  10  a.m. — Two  raw  eggs ;  two  glasses  of  milk ;  crackers ; 

pret/els. 

Dinner:  13.30  p.m. 

Cream  of  Tomatoes. 

Broiled  Sirloin  Steak. 

Stewed  Chicken. 

Boiled  White  Potatoes.         Stewed  Onions.  String  Beans. 

Steamed  Rice.         ,,  ,    ,  Macaroni. 

Salad. 

Apple  Tapioca.  Rice  I'udding. 

Crackers.  Cheese.  Nuts. 

Coffee. 

or 


606      HOME  TREATMENT  BY  SANATORIUM  METHODS 

Puree  of  Peas. 
Breast  Spring  Lamb.  Mint  Sauce. 

Prime  Ribs  of  Beef. 
Boiled  White  Potatoes.  Baked  Sweet  Potatoes. 

Spinach.  Stewed  Tomatoes. 

Lettuce  Salad. 
Baked  Apples.  Cup  Custard. 

Crackers.  Cheese.  Nuts, 

Coffee  ( demi-tasse ) . 
4  P.M. — Two  raw  eggs;  two  glasses  of  milk;  craekeri;  pretzels. 
Supper,  6.30  p.m. — One  raw  egg;  three  glasses  of  milk;  tea;  toast; 
fruit. 

8.30  P.M. — Two  glasses  of  milk. 

Summary. — Six  raw  eggs,  three  quarts  of  milk,  and  full  meal 
(Stockdale). 

Another  dietary  is  as  follows: 

7.30  A.M.— Milk,  I  pint. 

8.30  A.M. — Milk,  ^  pint;  bread  or  toast,  2  ounces;  Imtter,  ^  ounce; 

2  ounces  fish  or  bacon,  etc.,  and  an  egg. 

10.30  A.M.— Milk,  I  pint. 

11  A.M. — Milk,  I  pint;  bread,  2  ounces;  butter,  |   ounce;  fish,  2| 
ounces;  meat,  3  ounces;  milk  pudding,  5  ounces. 
Dinner. — Similar  to  lunch,  but  meat,  2  ounces. 

Cornet,  who  adopts  a  somewhat  lower  fat  standard  for  the  diet  in 
health  than  do  these  authors,  is  in  the  habit  of  prescribing  for  his  pa- 
tients on  the  following  lines : 

First  Breal-fast,  7  a.m. — Milk  (cocoa  or  coffee),  |  to  1  pint, 
with  one  or  two  eggs  stirred  in;  or  gruel,  or  meat,  bacon,  bread  and 
butter. 

Second  Breal-fast,  9  to  9.30  a.m. — Milk,  |  to  1  pint;  or  3  ounces 
strong  wine  (sherry,  port,  marsala),  bread  and  butter. 

Noon  Meal,  1  p.m. — Soup;  entree;  fish;  roast  venison;  fowl,  with 
vegetables;   preserves  and  salad;  pudding;  bread,  butter,  and  cheese; 

3  ounces  red  wine,  or  -|  pint  heer. 

Afternoon  Meal;  4  p.m. — Milk  (cocoa),  -I  to  1  pint,  with  one  or  two 
eggs  stirred  in;  bread  and  butter  (honey). 

Supper,  7  p.m. — Roast  meat;  vegetables;  cold  meat  (ham)  ;  roasted 
potatoes;  bread  and  butter;  3  ounces  wine,  or  ^  to  1  pint  beer  or 
milk. 

9  P.M. — Milk,  i  to  1  pint;  1  zwieback,  cakes,  or  bread. 


FOOD  GOT 

Lucas  gives  the  amount  of  the  various  forms  of  food  which  are 
necessary  as  follows: 

Breakfast. — Porridge,  \  pint,  with  2  ounces  of  sugar;  2  rashers  of 
bacon  and  2  eggs  (or  chop,  steak,  or  fish)  ;  bread,  4  ounces;  butter,  2 
ounces;  |  pint  of  tea  or  coffee;  milk,  1  pint. 

Midday  Meal. — Soup  (optional)  ;  fish,  3  ounces  (or  poultry),  with 
butter,  2  ounces ;  2  or  3  slices  of  meat,  4  ounces ;  potatoes,  4  ounces ; 
cabbage  and  other  vegetables,  4  ounces;  pudding  (various  kinds),  6 
ounces;  cheese,  2  ounces;  bread,  4  ounces;  butter,  2  ounces;  milk,  1  pint 
(or  cocoa),  with  one  or  two  eggs  stirred  in;  bread  and  butter  (honey). 

Supper  preceded  by  one  fourth  to  one  half  hour  of  rest. 

Supper,  7  p.m. — T?oast  meat;  vegetables;  cold  meat  (ham)  ;  roasted 
potatoes;  bread  and  butter;  100  c.c.  of  wine,  or  ^  to  -J  liter  (quart)  of 
beer  or  milk. 

9  P.M. — Milk,  I  to  f  liter  (quart)  ;  1  zwieback,  cakes,  or  bread. 

The  rest  before  meals,  which  I  prescribe  even  for  fairly  strong  pa- 
tients, increases  the  consumption  of  food. 

Tuberculous  patients  with  a  temperature  seem  to  be  able  to  take 
and  digest  an  amount  of  solid  food  which  under  other  febrile  conditions 
would  not  be  tolerated.  Any  dietary  suggested  will  have  to  be  modified 
to  suit  the  individual.  If  any  other  argument  was  necessary,  this  is 
sufficient  to  justify  the  claim  for  constant  medical  supervision  in  these 
cases,  and  infinite  tact  and  perseverance  are  necessary.  The  simplest 
diet  is  that  of  milk  and  eggs ;  if  patients  take  enough  of  these,  other 
food  may  be  largely  dispensed  with,  and  yet,  in  the  employment  of  these, 
tact  and  judgment  will  have  to  be  displayed.  A  large  percentage  of 
patients  can  take  raw  milk — even  many  who  think  and  say  they  cannot. 
Still,  there  remains  a  percentage  of  patients  who  cannot  take  milk  at 
all,  or  for  whom  the  milk  must  be  modified  in  some  way,  or  peptonized. 

Appetizing  and  Bitter  Tonics 

"When  the  desire  for  food  is  poor,  appetizers  and  bitter  tonics  may  be 
indicated.  Among  these  may  be  mentioned  alcohol,  which  in  moderate 
amount,  and  either  plain  or  with  vegetable  bitters,  not  only  stimulates 
the  appetite,  but  improves  tlie  condition  of  the  body  as  a  whole.  In  this 
connection  the  following  will  be  found  of  service : 

!^   Tr.  nucis  vomicae    ."ij ;     5  gm. 

"    gentianse  composit.,  ) 

«   ".     1  .,     >  aa .^i] ;  60 

cmclionffi  composit.,  I  "^  ■* 

M.     Sig. :  Dose  3j,  in  a  wineglassful  of  water  before  meals. 


608  HOME   TREATMENT   BY   SANATORIUM    METHODS 

AIR    AND    ENVIRONMENT 

The  life  history  of  the  tubercle  l)acillus  outside  the  body,  and  our 
knowledge  of  its  existence  in  man  and  animals,  all  teach  us  that  fresh 
air  exercises  an  unfavorable  effect  on  its  growth.  Tubercle  bacilli  dried 
and  exposed  to  the  sunlight  lose  their  virulence  in  a  few  days;  in  dark, 
illy  ventilated  rooms  they  may  retain  it  for  many  months.  From  the 
animal  kingdom  the  same  testimony  is  obtained;  tuberculosis  is  not 
found  in  the  monkey  in  his  jungle  life.  In  captivity  it  is  tlie  disease 
with  which  he  is  affected,  and  it  probably  accounts  for  more  deaths  tlian 
all  other  diseases  combined. 

The  same  evidence  is  furnished  by  the  human  family.  Tuberculosis 
is  comparatively  rare  in  the  rural  districts.  In  the  negro,  in  his  unciv- 
ilized state  and  even  in  his  state  of  bondage,  it  was  comparatively  un- 
known. jSTow  the  deaths  in  that  race  from  this  disease  are  three  or  four 
times  as  great  as  among  the  whites. 

The  congested  districts  of  our  cities — our  slums,  sweat  shops,  "  lung 
blocks,"  etc. — furnish  uncanny  but  instructive  pictures  to  which  we  can- 
not shut  our  eyes.  Fresh  air  in  some  of  the  abodes  of  the  poor  is  more 
difficult  to  obtain  than  fresh  food,  and  tliese  "  lung  blocks  "  exact  their 
tribute  year  after  year.  Fortunately  for  the  human  race,  health  boards 
and  philanthropists  are  taking  active  hold  of  this  problem,  and  are 
forcing  conscienceless  landlords  to  respect  the  commandment,  "Thou 
shalt  not  kill."  With  these  facts  in  our  possession,  it  is  easy  to  see  the 
important  role  which  pure  air  plays  in  checking  the  spread  of  tlie  disease, 
and,  therefore,  the  saving  of  human  life. 

It  is  not  in  the  least  necessary  or  even  desirable  to  draw  the  line  in 
this  respect  between  the  patieiit  in  the  sanatorium  or  out  of  it ;  ]nire  air 
and  an  abundance  of  it  is  a  siiie  qua  non.  How  this  is  to  be  best  ob- 
tained is  a  problem  tliat  will  differ  in  almost  every  case,  and  it  will  often 
tax  the  ingenuity  and  sagacity  of  the  physician  to  the  utmost.  Mani- 
festly, the  problem  is  more  beset  with  difficulties  in  the  slums  tlian  in 
the  abodes  of  the  rich,  and  yet  the  prejudices  of  the  latter,  and  their 
ignorance  of  hygienic  laws  as  well,  often  present  difficulties  in  tliis  direc- 
tion that  are  greater  than  the  obstacles  that  poverty  enforces  in  the  case 
of  the  poor. 

AVhatever  the  financial  condition  or  social  status  of  the  patient,  fresh 
air  must  be  demanded.  This  can  l)e  obtained  in  most  instances  by  the 
physician  of  average  ingenuity  and  whose  heart  is  in  his  work,  for  be 
it  said  to  the  credit  of  the  human  race,  it  is  ever  ready  to  alleviate  dis- 
tress when  the  cause  is  just.  I  have  never  yet  been  refused  aid  for  a 
sufferer  for  whose  honesty  I  could  vouch ;  so  that,  when  improved 
hygienic  surroundings  are  necessary,  they  can  usually  be  obtained.     It 


AIR   AND   ENVIRONMENT  609 

is  simply  necessary  to  have  a  directing  liand.  Again,  the  district  nurse 
has  demonstrated  how  order  and  cleanliness  may  be  brought  out  of  chaos 
and  filth,  and  Pratt  and  others  have  shown  the  scientific  world  what 
truly  marvelous  results  may  be  obtained  with  unfavorable  environment 
and  unfriendly  climatic  conditions. 

Education  is  the  touchstone  that  brings  about  the  wonderful  trans- 
formation. Teach  the  sufferer  that  fresh  air  is  not  to  be  feared,  but 
rather  to  be  coveted,  and  a  great  stride  in  the  fight  will  have  been  made. 
The  temjjerature,  when  cold,  or  even  if  it  is  raining  or  snowing,  does  not 
prevent  living  a  large  portion  of  the  time  in  the  open  air.  It  is  essential 
to  keep  the  body  warm  and  dry  l)y  appropriate  covering.  At  a  minimum, 
eight  to  ten  hours  a  day  should  be  spent  in  the  open  air,  and  as  much 
more  as  practicable,  and  a  tent  life  away  from  the  dust-laden  and  pol- 
luted air  of  cities  is  to  be  desired.  If  a  tent  life  cannot  be  obtained — 
and  it  is  not  essential — as  near  an  approximation  as  the  means  and  en- 
vironment of  the  patient  will  admit  must  be  secured.  He  must  live  out 
of  doors  while  the  sun  is  up,  and  at  night  he  must  sleep  with  his  win- 
dows open,  though  not  in  a  draught. 

It  is  to  be  deplored  that  civilized  man  tries  to  subvert  the  laws  of 
nature.  His  life  is  spent  in  a  race  for  wealth  and  preferment;  and  it 
too  often  happens  that,  when  these  are  obtained,  his  capacity  for  enjoy- 
ment is  gone,  and  all  that  is  left  to  him  is  the  privilege  of  bequeathing 
to  posterity  his  life's  blood  coined  into  dollars.  The  business  of  life  in 
the  cities,  whether  it  be  to  gain  a  bare  subsistence  or  an  effort  to  main- 
tain social  position,  is  subversive  of  the  laws  of  nature.  "When  the  sun 
has  sunk  and  the  animal  and  vegetable  world  are  at  rest,  the  sweat- 
shop worker,  wearied  in  body,  is  busy  at  his  task;  the  society  devotee, 
with  less  excuse,  in  like  manner  weary  of  bod}',  but  from  a  different 
cause,  in  a  different  way — is  busy.  The  bodies  and  minds  of  both  are 
worn  with  the  struggle,  differing,  it  is  true,  in  its  aims  and  necessities, 
but  similar  in  its  ravages  on  the  constitution. 

Regularity  and  order  are  rules  of  our  environment  here;  and  the 
"  early  to  bed  and  early  to  rise  "  is  something  more  than  a  saw.  It  has 
been  found  that  in  this  disease,  especially,  it  is  well  to  have  patients 
follow,  as  nearly  as  possible,  the  course  of  the  sun — to  rise  with  it  and 
to  retire  with  it.  Naturally,  it  is  at  best  one  of  compromise  and  environ- 
ment.   Tlie  nearer  we  can  approach  the  primitive  state,  the  better. 

In  a  tent  existence,  if  possible,  it  is  best  to  have  the  abode  arranged 
so  that  the  necessary  toilet  arrangements  may  be  carried  on  in  comfort, 
protected  from  the  inclemencies  of  the  weather  which  are  to  be  encoun- 
tered in  any  climate,  but  the  sleeping  and  living  of  the  patient  should 
be  in  the  open.  This  does  not  materially  increase  the  expense  of  such 
an  existence,  for  a  tent,  divided  so  that  a  closed  portion  is  reserved  for 
40 


610      HOME  TREATMENT  BY  SANATORIUM  METHODS 

these  purposes,  is  not  diflficult  to  devise  and  maintain.  The  tent  sliould, 
in  all  cases,  have  a  lloor  elevated  a))ove  the  ground;  the  location  should 
be  well  drained,  and  protected  as  far  as  possible  from  winds.  These 
points  are  essential.  As  to  surroundings  of  pines  or  fir  trees,  a  sandy, 
porous  soil,  and  a  particular  climate  for  the  individual  case,  these  are 
to  be  desired,  but  not  essential. 

When  the  patient  is  to  be  cared  for  in  his  home,  the  following  details 
concerning  his  care  are  needful :  Pure  air,  nourishing  food,  and  the  con- 
stant supervision  of  an  able  medical  adviser.  The  patient's  room  should 
have  an  air  capacity  of  approximately  three  thousand  cubic  feet;  more 
does  no  harm,  less  makes  an  undesirable  eneroaclmient,  but  in  any  room 
not  only  is  its  size  to  be  considered,  but  its  location  and  ventilation  as 
well.  In  northern  latitudes,  except,  perhaps,  in  the  summer,  the  room 
should  have  a  southern,  southeastern,  or  southwestern  exposure,  so  that 
the  benefit  of  the  sun  can  be  had  a  large  part  of  the  day;  in  tropical 
climates  and  in  summer  it  may  be  desirable  to  change  this. 

The  location,  number,  and  size  of  the  windows  is  also  important. 
They  should  extend  almost,  if  not  quite,  to  the  ceiling,  and  unnecessary 
brackets  and  abutments  should  be  avoided,  as  they  tend  to  catch  dust. 
The  angles  of  the  room  should  be  obliterated  as  far  as  possible ;  e.  g., 
those  between  the  floor  and  wall,  and  wall  and  ceiling.  These  may  be 
rounded  by  metal  or  cloth,  that  may  be  painted.  It  is  preferable  to 
paint  the  walls,  because  they  may  then  be  cleansed  more  frequently  and 
properly.  Unnecessary  curtains  and  hangings  of  every  sort  are  to  be 
avoided,  as  are  also  Venetian  blinds,  since,  while  they  shut  off  the  light 
and  some  heat,  they  still  collect  quantities  of  dust.  To  keep  out  the 
light  when  it  is  not  desired,  I  know  of  nothing  better  than  tha  modern 
opaque  roller  shade. 

The  floors,  if  of  wood^  should  be  painted  or  waxed,  so  that  they  may 
be  cleaned  readily.  Whatever  the  floor  surface,  it  should  be  made  non- 
absorbing,  so  that  it  may  be  wiped  up  thoroughly.  Carpets  should  have 
no  place  in  the  room,  but  a  few  rugs  may  be  allowed.  In  this,  as  in 
many  other  ways,  the  rich  have  very  little  advantage  of  the  poor.  A 
Persian  rug  costing  many  hundreds  of  dollars,  infected  by  tuberculous 
sputum,  is  not  apt  to  be  consigned  to  the  trash  barrel — it  matters  not 
what  the  wealth  of  the  patient  may  be — whereas  the  morning  newspaper, 
on  which  the  cuspidor  of  the  poor  usually  rests,  is  destroyed  without 
hesitation  when  it  becomes  soiled. 

With  reference  to  cuspidors,  while  they  are  frequently  spoken  of  in 
derision  as  an  American  invention,  the  writer,  as  an  American,  is  glad 
to  acknowledge  their  paternity.  I  believe  them  to  be  the  greatest 
prophylactic  device  employed  in  preventing  the  spread  of  tulierculosis. 
Whatever  may  be  said  on  this  score,  pro  and  con,  it  is  certain  that  the 


AIR   AND   ENVIRONMENT  GU 

average  poor  patient  is  not  al)le  or  willing  to  furnish  himself  with  cloths 
or  tissue-paper  napkins  into  which  to  expectorate;  and,  while  well-to-do 
patients  are  able,  many  are  unwilling  to  take  the  trouble  which  the 
employment  of  cloths  or  napkins  entails.  I  consider  a  cuspidor  half 
filled  with  an  efficient  germicide,  or  simply  water,  less  dangerous  than 
any  cloth  on  which  the  sputum  is  apt  to  dry,  and  from  which  bacilli 
must  escape  when  they  are  used. 

The  chairs  should  be  constructed  for  comfort  rather  than  beauty,  and 
some  covering  which  may  be  disinfected  and  washed  may  be  i;sed.  For 
the  average  patient  some  t3'pe  of  reclining  chair  (e.  g.,  the  average 
steamer  chair,  which  is  inexpensive)  will  be  needed.  The  room  should 
be  on  the  first  floor,  so  as  to  save  the  patient  the  necessity  of  climbing 
flights  of  stairs;  it  should  be  contiguous  to  the  bathroom  and  toilet,  so 
that  the  wants  of  nature,  which  are  at  times  exacting,  may  be  met  with- 
out undue  fatigue.  It  should  be  heated  by  hot  water  or  steam  prefer- 
abl}',  and  should  be  lighted  by  electricity.  While  no  climate  is  univer- 
sally adapted  to  all  patients,  still,  the  average  case  will  do  best  in  a  mild, 
equable  climate.  A  sultry,  depressing  climate  is  to  be  avoided;  a  brac- 
ing climate  with  plenty  of  sunny  days  is  to  be  desired.  Climates  in 
which  sudden  atmospheric  changes  and  high  winds  prevail  are  undesir- 
able. The  air  should  be  free  from  dust  and  smoke,  and  the  soil  should 
be  sandy  or  porous.  A  moderate  altitude  above  the  sea  level  is  advan- 
tageous. 

ISTo  hard-and-fast  daily  routine  can  be  laid  down  for  all  patients. 
Any  regulations  that  may  be  prescribed  will  have  to  be  modified  to  suit 
the  individual  needs  That  employed  at  tlie  Xordrach  Sanatorium  for 
convalescent  patients  able  to  take  ordinary  exercise  will  serve  as  a  good 
working  l)asis. 

The  following  is  an  outline  of  the  daily  routine  observed  at  Xordrach : 
The  patient  is  called  at  seven  o'clock  in  the  morning,  and  in  the  colder 
months  the  windows  of  his  room  are  tlien  closed,  in  order  that  the  room 
may  be  comfortably  warm  while  he  dresses.  This  closing  of  the  win- 
dows at  this  time  serves  another  ])uri)ose,  in  that  the  air  of  the  room 
immediately  tends  to  become  "stuffy"  to  those  accustomed  to  open-air 
methods.  Consequently,  there  is  a  direct  incentive  to  patients  to  get 
up.  The  patient  then  takes  his  temperature  (rectal),  and  rises  not  later 
than  7.30,  and  has  a  shower  bath,  at  a  temperature,  in  most  cases,  agree- 
able to  himself.  He  must  avoid  overexertion  in  drying  himself.  On 
completion  of  his  dressing,  he  should  open  the  windows. 

Breakfast  is  at  eight  o'clock.  Directly  after  breakfast,  or  at  8.30, 
the  patient  starts  out  for  his  morning  walk,  the  length  of  which  is  grad- 
uated according  to  his  condition.  He  walks  deliberately,  avoiding  any 
strain,  dyspnea,  or  perspiration,  until  he  has  arrived  at  his  destination. 


612      HOME  TREATMENT  BY  SANATORIUM  METHODS 

and  waits  there  resting  in  the  fresh  air,  but  protected  from  the  wind, 
until  it  is  time  for  him  to  start  home  again. 

At  11.45  he  must  be  in  his  own  room,  where  the  windows  have 
shortly  before  been  shut,  and  must  take  his  temperature.  In  five  or  ten 
minutes  he  should  open  the  windows.  Between  twelve  and  one  o'clock 
he  lies  resting,  and  alone,  at  full  length  on  a  sofa  chair  near  the  window. 

At  one  o'clock  he  leaves  his  bedroom  or  shelter,  and  has  luncheon, 
the  principal  meal  of  the  day,  with  his  family.  Not  later  than  2.45  he 
must  start  on  his  slow  afternoon  walk,  which  is  the  shorter  walk  of  the 
day.  He  rests,  as  before,  when  he  arrives  at  his  destination,  and  returns 
slowly,  so  that  he  reaches  home  at  5.30,  or,  if  it  is  very  cold,  at  about 
4.45.  He  again  takes  his  temperature,  opens  the  windows,  which  have 
been  closed  shortly  before  his  return,  and  rests  alone  until  dinner  time. 

At  seven  o'clock  he  joins  his  family  at  dinner.  After  dinner  he  may 
spend  half  an  hour  to  an  hour  in  the  dining  room,  or  preferaljly  in  some 
suitable  recreation  room,  under  open-air  conditions.  The  patient  retires 
to  his  own  room  at  nine  o'clock,  opens  the  windows,  and  takes  his  tem- 
perature.   He  should  be  in  bed  at  9.30,  or  not  later  than  ten  o'clock. 

REST    AND    EXERCISE 

A  fundamental  principle  in  the  repair  of  tuberculous  tissue  is  rest. 
A  tuberculous  joint  is  rested  by  putting  it  up  in  a  splint;  in  cases  of 
Pott's  disease  the  patient  is  placed  in  a  plaster-of-Paris  corset;  in  tuber- 
culous pleurisy,  limit  the  excursions  of  the  chest  by  means  of  adhesive 
strips;  in  pulmonary  tuberculosis,  if  the  process  is  active,  general  rest 
is  prescribed. 

To  those  who  have  not  made  a  special  study  of  the  disease,  the  good 
results  obtai"ned  by  rest  would  seem  almost  chimerical,  and  yet  they  are 
demonstrable  verities.  Even  witliout  the  administration  of  drugs  the 
fever  disappears,  tlie  night  sweats  diminish,  the  cough  grows  less,  and 
the  patient  takes  on  flesh.  I  think  this  doctrine  of  rest  is  not  now  dis- 
puted by  those  having  considerable  experience  in  the  treatment  of  this 
disease.  It  was  on  this  theory  that  Forlanini,  and  later  Murphy,  Brauer, 
and  others,  suggested  tlie  ])lan  of  obtaining  rest  for  the  tuberculous  lung 
by  introducing  nitrogen  gas  into  the  pleural  cavity,  thus  causing  the 
lung  to  collapse,  and  producing  a  state  of  rest  which  lasts  until  the  gas 
is  absorbed. 

Eest  does  not  cure  all  cases  of  tuberculosis,  but  it  is  always  indicated 
where  there  is  hyperpyrexia,  where  the  night  sweats  are  exhausting, 
where  the  cough  is  incessant,  where  the  prostration  and  dyspnea  are 
great,  and  where  there  is  a  tendency  to  pulmonary  hemorrhage.  Wliere 
the   morning    temperature    is    99°    F.,    and    the    evening    temperature 


REST  AND  EXERCISE  613 

100°  F.  or  more,  rest  tliroughout  the  entire  day  should  be  enjoined. 
On  the  other  hand,  when  the  active  stage  of  the  disease  is  checked, 
exercise,  intelligently  directed  and  faithfully  carried  out,  is'  to  be  pre- 
scribed. This  must  be  undertaken  gradually,  and  stopped  at  the  return 
of  fever  or  the  production  of  too  great  fatigue. 

Some  exercise  may  be  obtained,  even  by  patients  who  are  confined 
to  their  rooms,  by  the  employment  of  massage.  This  stimulates  the  cir- 
culation and,  to  an  extent,  improves  the  general  nutrition,  but,  like 
other  exercise,  must  be  directed  intelligently;  and,  if  it  produces  too 
much  fatigue  or  brings  about  a,  rise  of  temperature,  it  must  be  curtailed 
or  abated. 

The  simplest  form  of  exercise  outside  of  this  is  walking.  This 
should  be  taken  at  first  on  the  level,  and  afterwards,  as  the  strength  in- 
creases, hill  climbing  may  be  prescribed ;  it  strengthens  the  leg  muscles, 
improves  the  action  of  the  heart,  and  thereby  the  general  nutrition  is 
improved.  The  hill  climbing  should  be  done  gradually,  and  so  that  the 
ascent  comes  in  the  beginning  rather  than  at  the  end  of  the  walk.  If 
fatigue  ensues,  a  rest  should  be  taken.  The  form  of  exercise  should 
conform  as  nearly  as  possible  to  the  tastes  of  the  patient,  and  that  which 
interests  and  attracts  him  should  be  indulged  in  as  far  as  possible.  This 
falls  in  line  with  the  directions  given  for  food.  "Within  certain  limits 
that  food  is  most  effective  which  is  toothsome  to  the  patient,  and  that 
exercise  accomplishes  most  good  which  is  most  attractive  or  most  inter- 
esting to  him. 

Dr.  Paterson,  of  the  Frimley  Sanatorium,  has  prescribed  a  graded 
system  of  exercise  which  may  be  varied  to  suit  the  individual  case,  but 


Fig.  152.— Grade  1.  B.\skets  Holding  About  12, 18  and  24  Pound.s  of  Mold  or 
Other  Material.  Patients  carry  these  a  distance  of  50  yards  up  a  gradient 
of  1  in  10.7  (rising  14  feet),  80  loads  per  day. 

which  may,  nevertheless,  be  employed  as  a  useful  guide.  He  prescribed 
exercise  and  labor  for  two  periods  daily,  each  of  two  hours'  duration. 
A  patient  is  first  placed  on  Grade  1,  and  then,  as  improvement  shows 
itself,  successively  on  Grades  2,  3,  etc.     If  the  work  of  the  grade  is 


614 


HOME  TREATMENT  BY  SANATORIUM  METHODS 


found  to  cause  a  rise  of  temperature,  decrease  of  weight,  or  other  bad 
symptom,  the  patient  is  at  once  placed  on  a  lower  grade. 

The  grades  are  as  follows:  (1)  Slow  walking  exercise,  beginning  at 
two  miles  a  day  and  gradually  increasing  up  to  ten  miles  a  day;  (2) 
picking  up  fir  cones  and  firewood  in  the  grounds,  and  carrying  a  half 
basket  (weight,  11  pounds)  to  the  stack;  (3)  carrying  a  full  basket  of 
firewood  and  cones  (weight,  16  pounds)  ;  (4)  carrying  a  half  basket  of 
gravel  or  stones  from  the  gravel  pit  to  the  place  where  paths  are  being 
made  or  repaired  (weight,  21  pounds)  ;  (5)  carrying  a  basket  of  gravel 


Fig.  153. — Shovels  and  Spades  Used  in  Grade  2  and  3  for  Digging  Earth  and 
Lifting  it  into  Barrows.  (Large  shovels  used  also  in  concrete  mixing  as 
Grade  4.) 


or  stones,  the  weiglit  of  which  is  gradually  increased  up  to  38  pounds 
(see  Fig.  152)  ;  (6)  rolling  the  grass  or  gravel  (sixteen  men  pull 
a  roller  weighing  15  hundredweight;  (7)  digging  ground  already 
broken;  (8)  mowing  grass  with  a  lawn  mower;  (9)  digging  unbroken 
ground;  (10)  the  same  as  under  (9),  but  for  six  hours  daily  in- 
stead of  four  hours — i.  e.,  the  hours  usually  spent  at  rest  are  spent 
in  labor. 

No  patient  is  classified  on  discharge  as  "  arrested  "  unless  for  three 
weeks  continuousl}'  he  can  pass  one  or  otlier  of  the  following  tests: 


REST  AND   EXERCISE 


615 


Test  A. — For  a  patient  who  earns  his  living  by  manual  labor:  To  be 
able,  on  an  ordinary  diet  and  without  rest  hours,  to  use  a  pick  and 
shovel,  of  the  full  size  and  weight,  for  six  hours  daily,  and  to  maintain 
his  health.    The  shovels  and  sjaades  are  of  three  sizes,  weighing  2,  4,  and 


e 


0  e 


(ti 


Fig.  154. — Forks  of  Different  Weight  for  Graduated  Work  in  Grade  2. 

6  pounds,  respectively.     The  picks  vary  from  3  to  7  pounds  in  weight 
(see  Figs.  153,  154,  155). 

Test  B. — For  a  patient  who  does  not  earn  his  living  by  manual  labor 
— clerks,  shopmen,  or  salesmen :  To  be  able,  on  an  ordinary  diet,  to  per- 
form the  labor  of  Grade  6,  or  for  six  hours  daily,  for  three  weeks,  and 
to  maintain  his  health.  These  patients  are,  as  a  rule,  gradually  brought 
up  to  Grade  9,  and,  when  it  is  found  that  they  can  do  this  work,  they 
are  put  back  to  Grade  6  or  7.  The  theory  is  that  a  man  doing  the  work 
described  under  Grades  9  and  10,  who,  on  discharge,  will  engage  in 
work  involving  but  little  bodily  exercise,  would  suffer  in  health  from 
such  an  abrupt  transition.  Further  experience  is,  however,  necessary  on 
this  point.  In  some  cases  it  is  found  that  patients  are  unfit  for  Grade  9, 
but  that  they  can  be  raised  to  a  standard  of  lal)or  which  is  equal  to  their 
ordinary  work.  These  patients  arc  tested  before  discharge  on  the  grade 
to  which  they  have  attained,  but  they  are  not,  as  a  rule,  classified  as 
"  arrested." 


616 


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On  the  supposition  that  the  healthy  portion  of  the  lung  undergoes 
hypertrophy,  and  that  in  this  way  loss  of  tissue  is  compensated,  many 
authorities  have  advocated  pulmonary  gymnastics,  but  these  have  been 
opposed  by  Brehmer,  Liebermeister,  and  others,  for  reasons  already 
given,  viz.,  that  the  nearer  the  diseased  lung  tissue  approximates  a  con- 
dition of  rest,  the  more  readily  it  returns  to  the  normal. 


Fig.  155. — Pickaxes  of  Various  Weights  Used  in  Grade  4  for  Breaking 
Ground,  Excavating,  Etc.     This  being  the  hardest  work  possible. 

Within  the  last  few  months  the  untoward  effects  of  exercise  in  the 
active  stage  of  the  disease  have  been  impressed  on  me.  An  athletic 
young  man,  after  a  period  of  apparent  quiescence  in  his  lung  trouble, 
suffered  from  a  lively  exacerbation  in  which  he  had  serious  and  repeated 
hemorrhages,  rise  of  temperature,  etc.  After  the  hemorrhages  had 
ceased,  and  the  temperature  had  been  normal  throughout  the  twenty-four 
hours  for  several  days,  and  the  patient  was  eating  well,  sleeping  suffi- 
ciently, and  taking  some  exercise  in  walking  about  the  house  and 
premises,  I  thought  him  strong  enough  to  come  to  my  office,  instead  of 
my  visiting  him,  believing  that  the  ride  would  not  only  be  a  diversion 
for  him,  but  beneficial  in  other  ways.  Although  the  carriage  ride,  a 
distance  of  several  miles,  did  not  apparently  fatigue  him,  his  tempera- 
ture rose  that  night  to  105°  F.  Confinement  to  bed  for  several  days 
promptly  brought  it  do^vai  to  normal,  but  the  same  result  was  produced 
by  a  -second  trip. 

CLOTHING 

Clothing,  both  for  patients  confined  to  bed  and  those  going  about, 
should  be  light  but  Avarm.  In  each  case  the  patient  will  find  that  he 
can  keep  comfortable  with  less  clothing  by  a  little  practice  and  the  exer- 


HYDROTHERAPY  AND   HARDENING  617 

cise  of  a  certain  amount  of  will  power.  The  end  to  be  attained  is  to  keep 
the  body  warm,  but  not  to  overheat  it.  Any  clothing,  whether  bed  or 
body  clothing,  which  throws  the  individual  into  a  sweat  is  bad.  When 
confined  to  bed,  it  will  often  be  found  that  an  excess  of  covering  is  not 
needed  if  a  hot-water  bottle  is  applied  to  the  feet.  In  the  matter  of 
body  clothing,  it  is  well  to  cover  the  body  of  the  patient  with  woolen 
garments,  summer  and  winter,  the  weight  of  the  garments  being  gov- 
erned by  the  temperature  and  temperament  of  the  patient.  If  wool 
irritates  the  skin,  cotton,  linen,  or  silk  undergarments  may  be  worn. 
For  sudden  or  great  drops  in  temperature,  overgarments  of  varying 
weights  may  be  employed,  and  the  patient  should  not  start  out  on  a 
long  drive  or  walk  without  providing  against  these  contingencies.  The 
overcoat  or  wrap  is  especially  to  be  commended,  because  it  may  be  thrown 
off  easily  or  put  on  as  occasion  demands. 

HYDROTHERAPY  AND  HARDENING 

The  value  of  the  bath  in  cleansing  the  skin  of  dirt  and  grease  has 
been  recognized  from  the  earliest  times.  It  not  only  improves  the 
physiologic  activity  of  the  skin,  Imt  accelerates  the  circulation  of  the 
blood.  The  cold  bath  stimulates  the  peripheral  nerves,  and  produces  an 
invigorating  effect  on  the  body  as  a  whole.  At  first  the  cold  bath  cannot 
be  taken  by  all  patients,  the  shock  being  too  great. 

Some  patients  cannot  be  hardened  or  educated  into  taking  them. 
This  is  not  a  matter  of  mere  volition  on  the  part  of  these  patients,  but 
of  temperament  and  constitution.  These  patients  may  greatly  desire  to 
avail  themselves  of  this  invigorating  procedure,  and  may  strive  to  coop- 
erate to  their  utmost,  but,  in  spite  of  all  efforts,  they  fail  to  react.  In- 
stead, they  feel  depleted  and  benumbed ;  the  head  aches,  the  circulation 
is  depressed.  Instead  of  the  tingling  and  bodily  glow  which  should 
follow  the  bath,  they  remain  chilly  throughout  the  day ;  the  extremities 
are  cold  and  the  nails  and  lips  blue.  These  patients,  many  of  whom  are 
apparently  strong,  and  others  who  are  already  depleted  and  deliilitated 
from  the  ravages  of  the  disease,  should  confine  themselves  to  hot  and 
lukewann  batlis. 

The  process  of  hardening  can  be  carried  out  in  a  larger  percentage 
of  cases  than  would  at  first  sight  seem  possible,  if  the  physician  will 
exercise  sufficient  moral  suasion,  patience,  and  ingenuity ;  but  when  the 
aforementioned  train  of  symptoms  follow  the  cold  bath,  it  should  be 
abandoned.  Even  in  the  case  of  patients  who  can  take  it  and  experience 
a  marked  tonic  effect  therefrom,  it  should  be  dispensed  with  if  there 
is  a  tendency  to  hemorrhage.  Eliminating,  then,  those  patients  who 
for  one  reason  or  another  cannot  take  the  cold  bath,  it  will  be 
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found  tliat  by  far  tlie  larger  percentage  can  take  it,  and  witli  distinct 
benefit. 

In  the  case  of  feeble  and  more  bigbly  sensitive  patients,  they  will 
have  to  be  initiated  by  sponging  a  ])ortion  of  the  body  with  lukewarm 
water,  and  water  to  which  alcohol,  salt,  or  vinegar  has  been  added;  in 
the  more  difficult  cases  the  bath  should  be  preceded  by  dry  friction;  in 
fact,  in  all  cases  friction  should  be  done  during  the  process  of  the  bath. 
Gradually  the  temperature  of  the  bath  may  be  reduced  to  70°  or  00°  F. 

Patients  who  react  w^ell,  and  who  can  practice  friction  on  themselves, 
a  cold  plunge  on  rising,  lasting  from  one  to  two  minutes,  followed  by 
a  brisk  rubbing  with  a  coarse  bath  towel,  will  be  grateful  and  highly 
beneficial,  producing  a  degree  of  exhilaration  that  can  be  obtained  from 
no  other  procedure. 

Some  patients  prefer  to  take  a  cold  sponge  to  the  waist,  others  a 
shower  bath  or  a  needle  bath,  instead  of  the  plunge.  The  cold  plunges 
or  shower  baths  which  are  taken  for  their  tonic  effect  do  not  take  the 
place  of  the  hot  baths,  which  are  taken  to  cleanse  the  skin  of  its  im- 
purities, and  are  demanded  at  least  once  a  week. 

SYMPTOMATIC    TREATMENT 

Debility  and  Loss  of  Appetite  and  Weight. — Second  only  to  fever, 
in  the  earlier  manifestations  of  tuberculosis,  stand  debility,  loss  of 
appetite  and  weight.  These  latter  appear  early  in  the  course  of  the 
disease,  frequently  before  the  development  of  fever  or  sufficient  physical 
signs  to  enable  us  in  many  cases  to  make  a  diagnosis,  or  in  some  cases 
even  to  suspect  it.  In  other  words,  these  symptoms  are  characteristic 
of  so  many  conditions;  they  are  due  sometimes  to  overwork,  improper 
food,  distress  and  anxiety  of  mind,  poor  hygienic  surroundings.  In  such 
cases  tuberculosis  is  frequently  little  thought  of  by  the  doctor,  and  even 
less  so  by  the  patient  and  his  friends,  and  yet  the  name  consumption 
comes  from  these  important  symptoms  which  are  present  in  varying 
degrees  throughout  the  course  of  the  disease.  The  main  lesson  which 
the  physician  should  gain  from  this  is  to  go  more  thoroughly  into  the 
history,  symptoms,  and  physical  signs  of  the  case;  in  this  way  an  error 
of  diagnosis  may  be  avoided  and  the  patient's  chances  of  recovery  are 
greatly  increased. 

It  is  better  to  go  to  great  lengths  of  trouble  to  no  purpose  than  to 
neglect  needful  details  of  technic  and  later  reap  a  harvest  of  barren 
regrets.  It  is  not  meant  to  be  implied  in  this  that  an  early  diagnosis 
can  always  be  made;  it  is  only  to  put  the  physician  on  his  guard  and 
remind  him  of  what  he  already  knows — that  it  is  never  wise,  or  safe,  or 
just,  either  to  himself  or  his  patient,  to  outline  a  treatment  based  simply 


SYMPTOMATIC  TREATMENT  619 

on  tlie  feel  of  the  pnlse,  appearance  of  tlie  tongue,  and  loss  of  flesh. 
Tonics  and  general  directions  do  sometimes  (for  we  have  not  yet,  un- 
fortunately, a  specific  for  tuberculosis)  bring  about  a  restoration  to  the 
normal;  but  a  large  percentage  of  these  patients  will  come  back  sooner 
or  later  with  more  prominent  s^miptoms,  when  the  real  cause  of  the 
trouble  will  be  made  manifest. 

With  tlie  diagnosis  not  in  question,  the  symptoms  of  debility  and 
loss  of  weight  demand  intelligent  treatment,  more  tlian  all  others,  taking 
the  disease  from  its  beginning  to  its  end.  As  has  been  stated,  patients 
do  not  gain  in  weight  and  strength  when  the  tuberculous  process  is 
advancing  and  vice  versa.  Even  under  careful  treatment,  this,  in  the 
main,  is  true.  The  question  of  nourishment,  then,  is  of  the  greatest 
importance,  and  what  has  been  said  of  diet  and  hygiene  will  necessarily 
have  to  find  some  repetition  and  added  emphasis  here. 

It  is  doubtful  whether  any  considerable  loss  of  weight  and  bodily 
vigor,  in  the  absence  of  apprecialde  digestive  disturbance,  and  frequently 
when  it  is  present,  often  occurs  without  an  impaired  desire  for  food. 
Naturally,  when  the  ingestion  of  food  is  not  sufficient  to  make  good  the 
bodily  wastes,  whether  from  inability  to  obtain  food  either  in  sufficient 
quantity  or  proper  quality,  or  from  lack  of  desire  in  consequence  of 
disease,  the  weight  and  bodily  strength  will  wane.  In  tuberculosis  these 
may  be  corrected  by  overcoming  any  digestive  disturbance  by  forced 
feeding  with  wholesome  food,  and  by  tonics  which  stimulate  the  appe- 
tite, and  thereby  develop  a  craving  for  food.  Tlie  condition  may  also 
be  alleviated  by  the  administration  of  remedies  which  look  to  more  active 
blood  building  and  imjn-oving  the  nervous  tone. 

If  the  patient  has  a  coated  tongue  and  a  disturbed  digestion,  the 
first  indication  will  be  the  relief  of  these.  In  the  earlier  stages  of 
the  disease  this  is  not  difficult.  This  having  been  accomplished,  the 
quantity  and  quality  of  the  food  must  receive  consideration,  and,  as 
has  been  pointed  out,  these  patients  cannot  only  take,  but  often  digest, 
a  larger  quantity  of  food  than  would  be  desired  or  could  be  cared  for 
by  an  individual  in  health. 

Other  points  in  this  condition  to  be  borne  in  mind  are  that  these 
patients,  even  when  fever  is  present,  can  take  a  greater  quantity  of 
solid  food  and  demand  a  larger  percentage  of  fats  than  in  any  other 
disease.  For  these  reasons  the  feeding  requires  to  be  more  intelligently 
and  firmly  directed.  The  variety  and  preparation  of  food  accomplish 
much,  and  to  tliis,  no  doubt,  is  due  much  of  the  success  which  follows 
the  treatment  of  those  patients  wlio  have  been  pinched  by  poverty,  and 
to  whom  such  food  is  not  only  a  novelty,  but  a  luxury.  It  holds  good, 
too,  even  with  patients  in  easy  circumstances  who  have  paid  too  little 
heed  to  these  essentials.     Aside  from  tliese,  tlie  moral  influence  of  the 


620  HOME   TREATMENT   BY   SANATORIUM   METHODS 

physician  must  be  brought  into  play  to  teach  these  patients  to  take 
more  food  than  they  actually  crave. 

In  severe  cases,  liquid  food,  such  as  milk,  broth,  and  eggs,  will  have 
to  be  employed,  because  they  can  be  swallowed  without  mastication; 
but  it  has  been  found  that  a  larger  percentage  of  patients  do  best  on 
solid  food.  When  this  cannot  or  will  not  be  taken,  in  aggravated  cases, 
resort  to  the  stomach-tube  may  be  necessary,  but  this  is  infrequent. 
Again,  when  much  gastric  disturbance  is  present,  and  no  effort  of  will 
on  the  part  of  the  patient  will  enable  him  either  to  take  food  or  to 
retain  it  when  introduced  by  the  stomach-tube,  or  when  the  larynx  is 
so  affected  that  the  swallowing  of  food  or  of  a  stomach-tube  is  distress- 
ing, and  therefore  impracticaljle,  resort  may  be  had  to  rectal  feeding. 
Finally,  some  degree  of  nourislunent  may  be  obtained  by  inunction  of 
the  body  with  olive  oil  or  cocoa  butter.  Some  or  all  of  these  procedures 
may  be  necessary  in  appropriate  cases. 

Concerning  tlie  proteid  foods,  repetition  will  not  be  made  here,  but, 
in  the  matter  of  fats,  the  administration  of  butter  and  cream  and  oils 
is  again  emphasized.  These  are  not  only  valuable  as  foods,  but  serve 
to  keep  the  bowels  open. 

Cod-liver  oil  has  long  been  employed  in  the  treatment  of  tuberculosis, 
formerly  with  the  idea  that  it  had  a  specific  effect  on  the  disease  (and 
it  may  be  that  the  small  amount  of  iodin  wbich  it  contains  has  some 
effect),  but  now  it  is  regarded  chiefly  as  a  food.  It  was  formerly  given 
in  too  large  doses,  and  was  often  nauseous  from  the  impure  quality  of 
the  oil.  This  is  largely  corrected  now,  so  that  a  comparatively  pure  and 
relatively  tasteless  oil  may  readily  be  obtained.  The  oil  is  best  admin- 
istered plain,  as  every  emulsion  and  other  combination  is,  in  effect,  a 
compromise  with  the  patient.  A  little  practice  will  make  the  patient 
not  only  take  the  oil  plain,  but  like  it.  When  this  is  not  the  case,  a 
little  whisky  in  the  bottom  of  the  glass,  then  the  oil,  and  a  little  whisky 
on  top,  or  sherry  wine  instead  of  the  whisky,  will  readily  disguise  its 
taste.  If  these  fail,  an  emulsion  may  be  taken,  or  the  oil  may  be 
combined  with  malt  extract.  It  should  be  borne  in  mind,  however, 
that  the  best  of  these  preparations  do  not  contain  more  than  thirty  to 
forty  per  cent  of  oil.  When  the  oil  is  not  borne  well,  the  dose  should 
be  reduced  to  ten  or  fifteen  drops  at  a  time. 

Olive  oil  is  being  much  used  now.  It  is  not  so  nauseous  as  cod-liver 
oil,  is  better  borne  by  the  stomach,  and  exercises  a  wholesome  effect  on 
the  digestive  tract.  Much  of  the  so-called  olive  oil  of  the  trade  is  cotton- 
seed oil.     Wliile  not  so  palatable  as  olive  oil,  its  nutritive  value  is  high. 

Anemia. — The  blood  should  be  examined  not  only  to  determine  the 
percentage  of  hemoglobin,  actual  as  well  as  relative,  but  also  the  number 
of  red   blood-corpuscles.      Additional   information,   the   exact  value   of 


SYMPTOMATIC  TREATMENT  621 

which  is  as  yet  indeterminate,  may  be  obtained  from  the  opsonic  index, 
which  at  the  present  time  seems  to  promise  much.  Impoverishment 
of  the  blood  is  usually  coincident  in  tuberculosis  with  asthenia,  loss  of 
appetite,  and  the  other  symptoms  of  debility  already  mentioned. 

In  addition  to  proper  nourishment  and  fresh  air,  it  has  been  gener- 
ally found  necessary  to  administer  remedies  to  counteract  these  losses. 
To  this  end,  ii-on  in  some  form  is  indicated.  While  many  of  the  newer 
preparations  of  iron  have  been  employed  during  the  past  generation, 
the  trend  of  unbiased  clinical  experience  is  gradually  leading  us  back 
to  the  older  officinal  preparations,  whose  value  has  been  established  by 
time  and  experience — viz.,  the  tincture  of  the  chlorid  of  iron  and  car- 
bonate of  iron,  as  contained  in  Blaud's  pills,  and  the  sirup  of  the  iodid 
of  iron.  The  main  point  to  be  boiae  in  mind  in  the  administration  of 
these  and  other  salts  of  iron  is  not  to  give  too  much,  as  it  then  bur- 
dens the  alimentary  tract  and  causes  headache  and  other  disagreeable 
symptoms. 

Next  to  iron,  the  reconstructive  agent  which  has  for  years  been  valued 
highly,  and  which  still  holds  its  place,  is  arsenic.  This  may  be  adminis- 
tered in  the  form  of  arsenious  acid — dose  for  an  adult,  -^-q  grain  three 
times  daily — or  Fowler's  solution,  beginning  with  three  drops  and  in- 
creasing up  to  eight  drops.  Other  preparations  of  arsenic  ma}^  be  em- 
ployed which  meet  the  approval  of  the  clinician  and  the  demands  of  the 
case.  Arsenic  is  apt  to  produce  gastric  disturbances  and  puffing  of 
the  cellular  tissues  beneath  the  eyes.  When  these  occur  the  dose  must 
be  reduced. 

To  counteract  the  debility  and  improve  the  nervous  tone,  no  drug 
takes  the  place  of  stryclmin.  The  preparation,  usually  employed  for 
this  purpose  is  the  sulphate.  It  may  be  given  in  doses  ranging  from 
■To  to  "sV  grain  three  times  daily,  or  it  may  be  desirable  to  give  it  in  the 
form  of  tincture  of  nux  vomica,  from  which  we  get  not  only  the  tonic 
effect  of  the  drug,  but  its  action  as  a  stomachic  as  well;  of  this  10  to 
15  drops  may  be  given  three  times  daily.  When  excessive  nervousness, 
muscular  tremor,  twitching,  and  high  arterial  tension  are  produced,  the 
dose  should  be  reduced  or  the  drug  withheld  for  a  time. 

Any  of  the  above-mentioned  drugs  may  be  given  separately  or  in 
combination.  In  appropriate  cases  the  hypophosphites  will  also  prove 
of  value.  These  are  commonly  administered  in  the  form  of  compound 
sirup  of  hypophosphites  (U.  S.  Phar.)  or  the  more  recent  glycerophos- 
phates, which  are  prepared  with  and  without  sugar.  The  doses  of  these 
range  from  one  to  two  teaspoonfuls  three  times  daily. 

The  clearer  our  insight  into  diseased  processes  becomes  the  more 
we  find  it  desirable  to  confine  ourselves  to  single  drugs  or  simple  com- 
binations which  meet  the  particular  indication  rather  than  to  adminis- 


622  HOME   TREATMENT   BY   SAxNATORIUM   METHODS 

ter  a  combination  of  drugs,  many  of  which  add  an  additional  ]f)ad  to 
the  already  overburdened  system  of  the  patient. 

Fever. — Fever  is  an  early,  prominent,  and  frequently  distressing 
symptom  of  tuberculosis.  For  a  time  it  was  thought  that  the  pyrexia 
was  produced  by  the  presence  of  other  organisms  (e.  g.,  streptococci, 
staphylococci,  etc.),  as  these  are  commonly  found  associated  with  the 
tubercle  bacillus;  but  judging  from  clinical  experience  and  from  the 
results  of  administration  of  tuberculin,  we  are  justified  in  stating  posi- 
tively that  the  toxins  produced  by  the  tubercle  bacillus  do  produce  fever 
without  the  presence  of  other  organisms.  For  the  prevention  of  fever, 
or  to  diminish  it  when  present,  our  remedial  agents  may  be  classified 
under  three  subdivisions,  viz.:  (1)  rest  and  food,  (2)  hydrotherapy. 
(3)  medicines. 

It  has  been  proved  that  exercise  of  body  or  mind  elevates  the  tem- 
perature in  tuberculosis.  A  walk  beyond  the  endurance  of  the  patient, 
a  ride  taxing  his  strength,  or  any  undue  physical  exercise,  has  caused  a 
rise  of  temperature  of  one  or  more  degrees.  On  the  other  hand,  dis- 
tressing news  or  too  much  excitement  produce  the  same  effect.  An  im- 
proper quality  or  quantity  of  food  produce  a  like  result,  and  Cornet 
lays  special  emphasis  on  the  fact  that,  with  other  elements  of  error 
thrown  out,  the  patient's  temperature  tends  to  decline  the  nearer  you 
can  bring  him  to  a  solid  diet. 

When  the  patient's  temperature  is  elevated,  it  is  essential  to  give 
liini  all  the  bodily  and  mental  rest  necessary.  If  this  means  keeping 
him  constantly  in  bed,  let  it  be  so.  This  does  not  imply,  however,  that 
fresh  air  must  be  kept  from  him ;  quite  the  contrary  If,  from  the 
nature  of  his  surroundings,  the  patient  must  keep  to  his  bed,  free  ven- 
tilation of  the  apartment  must  be  maintained.  Change  of  environment 
seems  to  be  beneficial  and  desired  by  all  the  animal  kingdom,  and 
counts  even  in  matters  of  small  detail.  Hence,  when  possible  in  these 
cases,  it  is  effective  physically,  if  no  other  way,  to  change  the  patient 
from  his  sleeping  bed  to  a  couch  or  easy  chair,  from  his  room  to  a 
veranda  or  lawn,  such  change  being  accomplished  without  exertion  or 
thought  on  the  part  of  the  patient.  No  one  can  be  shielded  from  all 
trouble  in  this  world,  still  such  as  may  should  be  kept  from  the  patient 
and  he  should  not  be  allowed  to  receive  visitors  who  tax  his  energies  or 
who  are  injudicious  in  their  conversation.  It  may  be  stated,  generally, 
that  patients  whose  temperature  ranges  over  99.5°  F.  should  not  only 
abstain  from  exercise,  but  should  be  confined  to  Ijed  or  to  an  easy  chair 
until  the  temperature  shall  have  remained  normal  for  several  days. 
The  elTectiveness  of  rest  is  seen  in  the  improvement  which  comes  from 
the  immobilizing  of  a  tuberculous  joint,  the  checking  of  the  tuber- 
culous lung  process  by  the  development  of  a  pleurisy,  etc. 


SYMPTOMATIC  TREATMENT  623 

WJien  the  temperature  is  not  controlled  by  these  procedures,  or  even 
along  with  them,  hydrotherapy  may  be  employed.  The  temperature 
usually  rises  in  the  afternoon,  except  in  advanced  cases,  when  it  may 
remain  elevated  more  or  less  all  day ;  occasionally  a  reversal  of  the 
afternoon  rise  may  occur.  When  the  temperature  rises  it  may  be  re- 
duced by  a  hot  mustard  jo(jt  hath — two  heaping  tablespoonfuls  of  mus- 
tard in  a  foot  tub  two  thirds  full  of  water  of  a  temperature  as  hot  as 
can  be  borne  comfortably.  The  feet  should  be  allowed  to  remain  in 
this  until  they  tingle;  the  knees  are  covered  with  a  blanket.  Following 
this,  the  temperature  will  often  drop,  the  pulse  become  quiet,  headache 
(if  present)  will  disappear,  and  the  patient  lapse  into  a  tranquil,  refresh- 
ing sleep. 

If  the  foot  bath  fails  to  reduce  the  temperature,  resort  to  sponging 
may  be  had ;  this  may  be  general  or  include  only  portions  of  the  body — 
e.  g.,  the  arms,  legs,  or  head.  Water  of  the  ordinary  temperature  is 
commonly  employed,  though  in  cases  of  high  fever  ice  may  be  added, 
or  in  the  debilitated  and  where  the  temperature  is  low  the  water  may 
be  tepid.  In  the  former  the  effect  may  be  increased  by  the  addition  of 
alcohol  or  vinegar  to  the  water,  in  the  proportion  of  1  part  of  alcohol 
or  vinegar  to  3  or  4  parts  of  water.  Both  increase  the  rapidity  of  evapo- 
ration, and  not  only  remove  the  excess  of  heat,  but  are  especially  grate- 
ful to  the  patient. 

In  some  cases  a  general  hath  may  be  indicated,  and  in  still  others 
the  application  of  an  ice-cap. 

The  employment  of  drugs  to  reduce  the  temperature  is  to  be  depre- 
cated, and  is  only  to  be  resorted  to  when  all  other  measures  fail  and 
the  temporary  condition  of  the  patient  seems  to  demand  it;  for  it  must 
be  borne  in  mind  that  most  drugs  used  for  this  purpose  are  muscle 
paralyzers  and  are  effective  by  depressing  the  heart. 

The  safest  of  all  drugs  is  quinin,  but  it  does  not  belong  to  the  class 
mentioned.  It  will  sometimes  prove  efficient,  but  its  antipyretic  effect 
is  so  slight  that  it  will  usually  be  found  to  avail  little.  Of  all  the  coal- 
tar  derivatives,  I  prefer  phenacetin,  as  I  believe  it  to  be  the  safest. 
When  given  in  the  proportion  of  phenacetin,  5  grains,  citrate  of  caffein, 
1  grain,  and  camphor  monobromate,  ^  grain,  and  not  repeated  within 
three  hours,  I  have  never  observed  any  unpleasant  result.  Some  authori- 
ties give  antipyrin,  5  to  10  grains,  and  Koch  believes  that  pyramidon, 
not  exceeding  30  grains  in  twenty-four  hours,  is  more  beneficial  and  less 
depressing  than  any  of  the  class.  Acetanilid  I  have  found  to  be  a  dan- 
gerous drug,  and  I  do  not  prescribe  it.  Aconite  and  veratrum  viride 
act  on  the  circulation  and  likewise  depress  the  temperature.  They  may 
be  employed  in  cases  with  high  arterial  tension. 

It  is  to  be  constantly  borne  in  mind  that  in  the  employment  of  any 


624      HOME  TREATMENT  BY  SANATORIUM  METHODS 

of  these  antipyretic  drugs  we  are  compromising  both  with  the  patient 
and  the  disease.  They  add  to  the  immediate  and  temporary  comfort 
of  the  patient,  but  no  one  claims  that  they  exert  any  specific  effect 
whatever  on  the  disease.  They  should,  therefore,  be  employed  only  at 
intervals  and  when  all  other  measures  fail. 

Cough. — It  is  essential  to  understand  the  physiologic  nature  of 
cough  in  order  to  treat  it.  In  the  absence  of  some  abnormal  stimulus, 
cough  does  not  occur.  In  its  last  analysis,  cough  is  nature's  effort  to 
free  the  bronchial  tract  from  some  offending  stimulus.  Just  as  stimu- 
lation of  the  olfactory  ending  in  the  nasal  mucosa  by  means  of  a 
feather  or  by  the  edematous  pressure  produced  by  a  "  cold  "  will  pro- 
duce a  sneeze,  so  the  stimulation  of  the  laryngeal  tract  or  bronchial 
mucosa,  mechanically  or  by  congestion,  will  produce  a  cough.  In  both 
instances  the  process  is  purposeful.  It  is  an  effort  to  free  these  pas- 
sages so  that  the  normal  respiratory  movements  may  not  be  impeded. 
Again,  while  coughing  has  for  its  immediate  object  the  clearing  of  the 
respiratory  passages,  it  is  ultimately  for  the  benefit  of  the  body  as  a 
whole. 

Coughing  ma}'^  likewise  occur  from  other  reflex  stimuli.  A  cough 
results  from  a  mechanical  stimulation  of  an  area  in  the  external  audi- 
tory canal,  and  similarly  the  stimulation  of  the  terminal  filaments  of 
the  vagus  nerve  in  the  gastric  mucosa  may  produce  a  cough,  the  so- 
called  "  stomach  cough."  Highly  nervous  patients,  even  in  the  absence 
of  all  objective  causes,  will  have  a  dry,  hacking  cough,  which,  for  the 
want  of  a  better  name,  has  been  styled  a  nervous  cough.  Just  what 
produces  the  peculiar  cough  characteristic  of  pertussis  we  cannot  at 
the  present  time  say;  but  all  of  these  facts,  physiologic  and  pathologic, 
teach  us  that  we  must,  in  all  cases,  endeavor  to  determine  the  cause  of 
the  cough  before  we  attempt  to  abate  it. 

In  the  course  of  chronic  pulmonary  tuberculosis,  a  certain  amount 
and  kind  of  coughing  is  not  only  not  injurious,  but  positively  beneficial. 
When  the  cough  is  productive,  bringing  up,  as  it  often  does,  quantities 
of  sputum,  and  when  it  is  not  too  frequent,  it  is  beneficial  in  freeing 
the  bronchial  tubes  of  the  obstructing  mucus  and  detritus.  This  is 
especially  true  when  bronchiectasis  is  present.  A  mistake  not  infre- 
quently made  in  tuberculosis  is  to  treat  the  cough  rather  than  the  dis- 
ease. An  extreme,  it  seems,  has  been  reached  in  the  more  or  less  gen- 
eral proscription  of  cough  remedies  which  contain  sugar.  Opiates  and 
expectorants  are  at  times  demanded,  and  I  fail  to  see  why  we  should 
not  be  allowed  to  make  these  palatable  by  the  use  of  sugar.  If  sugar 
must  be  eliminated  because  it  upsets  the  digestion,  take  the  sirup  from 
the  griddle  cakes  when  you  take  it  from  the  cough  mixture.  The  writer 
believes  that  in  a  majority  of  instances  it  is  the  expectorant  drugs,  rather 


SYMPTOMATIC   TREATMENT  625 

than  the  sugar,  that  derange  the  digestion;  however,  there  are  cases 
from  which  sugar  should  he  withdrawn. 

In  the  control  of  the  cough  the  essential  thing  is  the  determination 
of  its  cause.  If  produced  by  a  disordered  stomach,  attention  to  the 
digestion  is  necessary.  An  inspection  of  the  external  auditory  canal  is 
never  out  of  place,  though  cough  produced  by  a  trouble  there  is  exceed- 
ingly rare.  A  very  common  cause  of  cough  is  found  in  catarrhal  and 
other  inflammations  of  the  pharynx  and  larynx.  Such  a  cough  is  little 
influenced  by  cough  remedies  unless  they  contain  enough  opiate  to  ob- 
tund  the  sensibilities  of  the  patient.  To  relieve  this  cough,  treatment 
of  the  local  condition  is  essential.  (Treatment  of  laryngeal  tuberculosis 
is  purposely  omitted  here.) 

In  catarrhal  inflammations  of  the  pharynx  and  larynx,  excellent  re- 
sults have  been  obtained  by  jjainting  the  affected  j^arts  once  daily  with 
the  following: 

]^   Potassii  iodidi gr.  x;       0.66  gm. 

Tr.  iodini,  ")  _  _  .  ,  .^ 

.    .  M-aa .^ss;         16.00     " 

Glycerm:,     J 

M.     Sig. :  Apply  to  throat  as  directed. 

This  may  be  augmented  by  spraying  the  throat,  p.  r.  n.,  with 

^  Mentholi    gr.  xx ;        1.30  gm. 

Camphor*    gr.  v ;          0.33    " 

Eucalyptoli   gtt.  iv ;       0.26    " 

Ac.  carbolic! gtt.  vj ;       0.40    " 

Liquid  albolene  or   (glymol)    §ij ;  60.00    '' 

M.     Sig. :  Use  in  atomizer. 

When  a  more  germicidal  and  a  stringent  effect  is  desired,  some  of 
the  silver  salts  may  be  employed — e.  g.,  one  per  cent  silver  nitrate  or 
five  to  ten  per  cent  argyrol,  applied  with  a  cotton  applicator  once  daily. 
The  additional  employment  of  a  spray  of  Dobell's  solution,  or  some  such 
alkaline  antiseptic  preparation,  f.  r.  n.,  will  often  prove  of  service. 

Xaturally,  tumors  or  ulcers  on  the  larynx  or  epiglottis  will  require 
treatment,  but  these  produce  a  cough  that  is  more  or  less  characteristic. 

Leaving  out  of  consideration  these  extrabronchial  factors,  we  come 
to  the  treatment  of  the  cough  which  commonly  forms  a  part  of  the 
history  of  pulmonary  tuberculosis.  In  the  first  place,  coughing  gets  to 
be  more  or  less  a  matter  of  habit  and  is,  more  than  would  generally  be 
believed,  under  control  of  the  will.  This  is  amply  demonstrated  in  all 
well-conducted  sanatoria  where,  considering  the  large  number  of  pa- 
tients in  varying  stages  of  the  disease,  the  amount  of  coughing  is  exceed- 


626  HOME   TREATMENT   BY   SANATORIUM    METHODS 

ingly  small.  Patients  may  be  educated  to  suppress  the  cough  when  it 
is  not  productive.  As  a  routine  measure,  patients  of  all  kinds,  both 
in  and  outside  of  sanatoria,  should  be  taught  to  favor  the  cough  when 
material  may  be  raised,  to  repress  it  as  far  as  possible  when  the  cough 
accomplishes  nothing.  It  is  surprising  how  much  the  cough  may  be 
repressed  in  this  way.  By  avoiding  excessive  exercise  in  which  respira- 
tion is  carried  on  through  the  mouth,  thereby  causing  undue  dryness 
of  the  throat,  the  cough  may  be  lessened.  Some  patients  must  be  con- 
fined to  bed  so  as  to  avoid  all  muscular  activity. 

In  like  manner,  by  lessening  or  leaving  off  the  use  of  tobacco  (espe- 
cially cigarettes,  which  are  almost  universally  inhaled)  and  avoiding 
alcoholic  excesses,  the  cough  resulting  from  local  congestion  produced 
by  these  habits  will  be  relieved  without  the  use  of  medicine. 

In  certain  coughs  which  are  more  or  less  irritative,  and  in  which 
the  patient's  rest  is  much  disturbed,  in  addition  to  the  local  applica- 
tions mentioned,  I  have  obtained  very  gratifying  results  from  the  use 
of  an  inhaler  which  covers  the  mouth  and  nose.  (For  ordinary  use  the 
Beverly  Robinson  inhaler,  a  perforated  zinc  mask  which  covers  the 
mouth  and  nose,  in  the  end  of  which  is  a  sponge,  and  which  is  held 
in  place  by  elastic  strings  going  round  the  ears,  is  commonly  employed.) 

The  following  prescription  has  given  much  relief: 

^   Mentholi  gr.  x ;       0.G6  gm. 

Alcoholi,         \ 

Creosoti,  I  aa    oijss ;      10.00     " 

Chloroformi,  ) 
M.    Sig. :  Put  a  few  drops  on  the  inhaler  and  use  for  fifteen  minutes, 
p.  r.  n. 

The  writer  has  found  this  to  act  well  in  cases  where  there  is  a  tend- 
ency to  hemorrhage.  The  chloroform  lessens  the  local  sensibility,  and  in 
diminishing  the  expulsive  efforts  of  the  cough  it  lessens  the  tendency  to 
hemorrhage.  Tiie  ])aticnt  must  be  removed  from  dust-laden  atmos- 
pheres, those  containing  irritating  gases,  and  from  regions  where  high 
winds  prevail.  In  a  large  percentage  of  cases  many  patients  will  not 
require  internal  remedies  for  the  cough,  or  if  so,  a  glass  of  hot  milk 
on  retiring  will  suffice.  On  rising,  or  immediately  after  breakfast, 
coughing  paroxysms  are  frequent.  This  cough  should  not  be  checked, 
as  it  serves  to  remove  the  secretions  which  accumulated  in  the  bronchial 
tubes  during  sleep;  after  this  the  patient  ordinarily  coughs  little,  or 
at  infrequent  intervals  throughout  the  day.  Sometimes  the  morning 
cough  is  sufficient  to  produce  emesis.  The  emesis  is  caused  by  me- 
chanical  stimulation    of   the   pharynx   by    the   mucopurulent    secretion 


SYMPTOMATIC   TREATMENT  627 

brouglit  up,  so  that  wlieri  the  cougli  lias  sul>sided  food  should  again 
be  taken. 

Remedies  should  be  administered  for  the  relief  of  the  cough  (1) 
when  it  is  so  incessant  and  rasping  as  to  disturb  the  rest  of  the  patient 
or  exhaust  his  strength,  (8)  when  the  cough  is  tight  and  the  frequent 
expulsive  efforts  cannot  remove  the  secretion  from  the  tubes,  and  (3) 
when  the  secretion  is  excessive  and  coughing  is  necessar}^  to  free  the 
tubes  in  order  that  the  respiratory  movements  may  go  on  properly. 

In  tlie  first  variety  the  cough  is  due  to  a  dryness  of  the  throat, 
trachea,  or  large  bronchi,  especially  the  throat.  In  this  variety  the 
sprays  and  the  inhalations  mentioned  are  of  service,  or  some  form  of 
lozenge,  or  swallowing  a  bit  of  vaselin  may  prove  efficacious.  Occa- 
sionally an  anodyne  has  to  be  used.  For  this  purpose,  heroin,  -^^  to  yV 
grain,  at  bedtime,  or  repeated  two  or  three  times  during  the  day,  will 
prove  quite  as  effective  as  many  of  the  more  complicated  cough  mixtures. 

When  the  cough  is  tight  and  frequent,  from  inability  to  raise  the 
expectoration,  two  demands  are  to  be  met  on  prescribing  a  cough  mix- 
ture: first,  an  opiate  to  diminish  the  frequency  of  the  cough,  and  sec- 
ond an  expectorant  to  loosen  the  secretion.  The  vehicle  is  more  or  less 
neutral,  so  far  as  its  effect  is  concerned,  and  there  is  a  tendency  to 
eliminate  sugar  from  it.  If  sugar  or  sirup  makes  the  dose  more  pala- 
table, there  is  no  reason  why  it  should  be  prohibited,  unless  it  is  neces- 
sary to  eliminate  sugar  from  the  dietary. 

The  following  prescriptions  are  of  service  in  this  variety  of  cough : 

^   Ammonii  muriatis oiv;  16.00  gm. 

Codeinae  sulphatis    gr.  ij-iv;       0.13-0.26    " 

Mist,  glycyrrhizae  comp 3iv;  120.00  " 

M.     Sig. :  Take  in  water  every  three  or  four  hours. 

I^   Spiritus  amnion,  aromatici.  qSs;  16.00  gm. 

Spiritus  clilorofprmi gtt.  xlviij-xcvj ;  3.16-6.32    " 

Heroin   gi"-  j ;  0.06  " 

Aquae  menth.  pip 5iij ;  90.00  " 

M.     Sig. :  Take  in  water  every  three  hours. 

1^  Morphinae  sulphatis gr.  j-ij ;        0.06-0.13  gm. 

Chloroformi gtt.  Ixiv;       7.60  " 

Aqua;  camphorae  or  menth.  pip..   3^^'j  120.00  " 

M.     Sig.:  One  teaspoonful  in  water  every  three  or  four  hours. 

!^   Heroin   gr.  j-ij :       0.06-0.13  gm. 

Spiritus  amnion,  aromat ,">iv;  16.00  " 

Aqua"    ^iij ;  !MKOO  " 

M.     Sig. :  One  teaspoonful  in  water  every  three  or  four  hours. 


628      HOME  TREATMENT  BY  SANATORIUM  METHODS 

When  the  secretion  is  excessive,  an  opiate,  combined  with  some 
agent  to  diminish  the  secretion,  is  indicated — e.  g.,  terpin  liydrate,  creo- 
sote, etc.  Heroin  with  terpin  hydrate  and  codein  and  creosote,  in  ac- 
ceptable vehicles,  or  in  pill  form,  will  yield  good  results  in  coughs  when 
the  expectoration  is  profuse.  Atropin  diminishes  all  glandular  secre- 
tion, and  for  that  reason  would  seem  to  be  applicable  here,  but  in  less- 
ening the  bronchial  secretion  it  also  diminishes  the  secretion  of  the 
glands  of  the  pharynx  and  larynx  and  trachea.  It  produces  a  dryness 
that  may  intensify  the  cough,  so  that  it  must  be  used  guardedly. 

Night  Sweats. — Night  sweats  occur  with  varying  degrees  of  inten- 
sity throughout  tlie  course  of  tuberculosis  in  a  large  percentage  of  cases. 
In  some  cases  they  are  absent  throughout;  in  others  they  are  slight, 
transitory,  or  limited  to  certain  areas  of  the  body;  in  still  others  they 
are  excessive,  being  sufficient  to  drench  the  bedclothing  and  mattress, 
as  well  as  the  clothing  of  the  patient.  They  occur  most  frequently  at 
night,  hence  the  name,  but  may  appear  at  any  hour  during  the  day 
or  night.  In  the  milder  cases  only  one  severe  sweating  period  occurs; 
this  usually  follows  the  evening  rise  of  temperature  and  when  the  first 
deep  sleep  takes  place.  It  may  occur  several  times,  so  that  it  thoroughly 
exhausts  the  patient,  becoming  a  veritable  nightmare  to  him,  and  in 
the  morning  he  arises  weakened  and  dejected. 

In  endeavoring  to  relieve  the  condition,  the  cause  producing  it  must 
be  understood.  It  should  be  borne  in  mind  that  it  is  a  toxemia — a 
septic  process  depending  on  the  absorption  of  toxins  into  the  blood. 
These  toxins  result  from  the  life  processes  of  the  tubercle  bacillus  (?), 
streptococcus,  staphylococcus,  and  perhaps  other  organisms;  in  brief,  it 
is  a  septicemia.  Therefore,  it  is  irrational  to  treat  the  sweat.  What 
should  be  attempted  is  to  try  to  eliminate  the  cause  of  the  sweat.  In 
this  it  is  not  intended  that  we  should  not  regard  the  comfort  of  the 
patient  and  alleviate  the  condition  as  far  as  possible,  any  more  than  we 
would  refuse  to  give  an  anodyne  to  relieve  the  excruciating  pain  of 
renal  colic  on  the  plea  that  it  is  not  the  pain  but  the  stone  that  we  are 
after. 

From  abundant  experience,  both  in  private  and  sanatorium  practice, 
it  has  been  demonstrated  that  the  night  sweats  will  cease  in  a  large 
percentage  of  cases  by  confining  the  patient  absolutely  to  bed,  properly 
feeding  him  and  giving  him  the  benefit  of  an  abundance  of  fresh  air. 
These  measures,  combined  with  such  tonic  remedial  agents  as  the  indi- 
vidual case  requires,  Avill,  except  in  advanced  cases,  in  a  comparatively 
short  time  bring  relief.  Until  this  takes  place,  and  in  advanced  cases 
from  which  nothing  may  be  expected,  the  sweating  must  be  treated, 
diminishing  it  as  much  as  possible  and  contributing  everything  to 
the  comfort  of  the  patient.      In  general  and  whenever  the  means  of 


SYMPTOMATIC  TREATMENT  629 

the  patient  permit,  the  clothing  of  the  patient  should  be  removed  as 
soon  as  it  becomes  wet,  and  his  body  sponged  with  alcohol  and  water, 
or  vinegar  and  water,  keeping  up  a  brisk  rubbing  all  the  while.  Fresh 
clothing  and  bedclothes  should  be  provided. 

Most  of  the  remedies  employed  to  prevent  or  diminish  the  sweat  act 
by  controlling  the  sjnnptom  and  exert  no  effect  on  the  causative  process. 
At  the  same  time,  these  remedies  are  neither  to  be  condemned  nor 
despised  if  the}^  contribute  to  the  patient's  comfort  until  the  defensive 
forces  of  the  body  are  reenforced  to  the  point  of  defeating  the  infecting 
agents.  Atropin,  in  doses  of  from  g-^  to  y^^j  grain,  is  the  remedy  com- 
monly employed  for  this  purpose,  and  the  one  which,  on  the  whole,  yields 
the  best  results.  This  may  be  repeated  two  or  three  times  in  the  twenty- 
four  hours,  if  necessary.  Aromatic  sulphuric  acid,  gtt.  10,  in  Avater  three 
times  daily,  and  agaricin,  -^  grain,  are  similarly  used.  They  may 
be  employed  singly  or  in  combination.  All  are  symptomatic  remedies, 
and  their  administration  should  be  stopped  as  soon  as  the  distressing 
S}Tnptom  abates. 

Gastro-intestinal  Disturbances. — Derangements  of  digestion  are  a 
common  accompaniment  of  tuberculosis,  and  present  one  of  the  great- 
est difficulties  in  its  treatment.  Where  the  digestion  is  normal,  forced 
feeding  is  a  comparatively  easy  matter,  and  where  superalimentation 
and  fresh  air  are  possible,  the  disease  is  not  apt  to  progress.  Unfor- 
tunately, the  alimentary  tract  is  not  always  equal  to  the  additional 
demand  and  catarrh  of  the  stomach  and  intestines  is  relatively  com- 
mon, so  that  when  patients  cooperate  with  the  physician  and  take 
an  excess  of  food,  they  are  unable  to  digest  it,  and  it  acts  as  a 
burden  rather  than  a  benefit.  In  a  majority  of  cases,  however,  the 
patient  suffers,  not  because  he  cannot  digest  the  food,  but  because  his 
appetite  is  impaired  and  he  cannot  be  induced  to  take  it.  For  this 
reason,  foods  which  can  be  swallowed  easily  and  digested  readily  are 
usually  recommended,  such  as  milk,  variously  modified,  eggs,  animal 
broths,  altliough  experience  teaches  that  those  patients  do  best  who  can 
take  a  solid  mixed  diet. 

The  digestive  disturbances  that  follow  in  the  wake  of  tuberculosis 
do  not  differ  essentially  from  those  which  characterize  other  diseased 
processes,  so  that  the  problems  to  be  solved  are  similar,  except  in  the 
case  of  tuberculous  enteritis. 

When  the  appetite  fails  the  digestive  stimulants  already  considered 
are  to  be  administered.  Again,  a  test  meal  and  examination  of  the 
stomach  contents  will  reveal  what  digestive  elements  are  lacking  in  this 
as  in  any  other  gastric  disorders.  When  it  has  been  shown  that  a  particu- 
lar element  of  the  gastric  juice  is  lacking,  a  restriction  of  the  food,  with 
reference  to  this,  and  the  supplying  of  the  lacking  ingredients  should 


630      HOME  TREATMENT  BY  SANATORIUM  METHODS 

be  attempted.  The  j^oint  to  be  empliasizecl  is  that  there  is  no  reason 
why  our  therapeutics  should  differ  when  gastric  disturbances  are  present 
in  tuberculosis. 

Creosote  has  for  a  long  time  been  regarded  as  a  remedy  for  tuber- 
culosis, but  as  our  experience  accumulates  we  are  forced  to  the  con- 
clusion that  its  beneficial  effects  come  from  improvement  of  the  diges- 
tion rather  than  from  any  specific  action  on  the  disease.  It  has  been 
proved,  it  is  true,  that  the  bacilli  can  be  killed  by  a  sufficient  amount 
of  creosote,  but  clinical  experience  has  also  shown  that  a  sufficient 
amount  of  it  cannot  be  gotten  into  the  circulation  to  produce  any 
specific  effect  without  deranging  the  digestion.  In  proper  dosage,  how- 
ever, it  produces  valuable  digestive  effects;  it  causes  the  dry  and  glazed 
tongue  to  become  moist ;  the  appetite  improves ;  the  fermentation  is 
lessened.  The  same  holds  true  in  intestinal  indigestion.  Pure  beech- 
wood  creosote  (gtt.  1-5)  is  employed,  administered  either  in  wine,  milk, 
or  capsule,  or,  what  is  thought  to  be  less  irritating  to  the  stomach,  car- 
bonate of  guaiacol  (5  to  10  grains)  or  creosotal  (5  to  10  grains)  may 
be  substituted. 

When  constipation  is  present  laxatives  should  be  emplo3'ed,  as  the 
comfort  of  the  patient  is  thereby  increased  and  his  nutrition  improved. 
No  remedy  has  been  found  to  supplant  sulphate  of  magnesia  or  an  occa- 
sional dose  of  castor  oil.  At  least  one  good  movement  daily  should  be 
the  rule.  When  diarrhea  is  present,  its  cause  should  be  ascertained  if 
possible;  frequently  an  improved  action  on  the  part  of  the  liver  will 
be  demanded,  and  a  purge  with  castor  oil  or  salts  will  bring  about  a 
return  to  the  normal.  This,  and  a  proper  regulation  of  the  diet,  are 
in  most  cases  all  that  is  necessary.  In  others,  however,  the  admin- 
istration of  bismuth  or  tanalbin  and  opium  will  be  demanded.  Wlien 
fermentation  is  excessive  and  undigested  food  is  passing  in  the  stools, 
aside  from  the  regulation  of  the  food  it  will  be  found  necessary  to  give 
pancreatin  (5  grains)  with  some  agent  which  prevents  fermentation, 
such  as  salol  (5  grains)  or  guaiacol  (5  grains),  asafetida  (5  grains), 
which  last  acts  not  only  in  this  direction,  but  also  serves  as  a  sedative 
to  the  nervous  system. 

I^   Extr.  pancreatis,  ")  _. 

Sodii  benzoatis,    j  ' ' ^^ '         '=' 

Asafetida   oss ;     2    " 

M.    Ft.  in  caps.  ad.    Xo.  XII.    Sig. :  One  capsule  three  times  daily. 

These  and  other  agents  which  will  appeal  to  the  individual  prac- 
titioner may  be  employed  with  or  without  the  addition  of  opium. 
Charcoal,  by  its  mechanical  action  in  absorbing  many  times  its  volume 
of  gas,  is  highly  recommended  by  some.     When  tlie  accumulation  of 


SYMPTOMATIC  TREATMENT  631 

gas  is  great,  it  produces  much  l)0(lily  discomfort  and  mental  distress, 
not  only  by  its  mechanical  pressure  on  the  heart  and  lungs,  but  by  its 
absorption.  In  this  condition  a  brisk  cathartic  is  indicated  and  im- 
mediate relief  may  be  obtained  by  an  asafetida  enema  of  tincture  of 
asafetida,  and  warm  water.  The  eifect  of  this  is  enhanced  by  giv- 
ing it  through  a  rectal  tube,  and  after  its  use,  if  the  gaseous  disten- 
tion still  is  great,  the  rectal  tube  may  be  inserted  and  left  in  place  for 
several  hours.  Of  course  this  effect  is  only  temporary,  but  it  at  times 
means  mucli  to  the  patient's  bodily  comfort  and  relieves  his  mind. 

Hemorrhage. — Of  all  tlie  symptoms  of  tuberculosis,  hemorrhage  is, 
perhaps,  the  most  alarming  to  the  patient  and  his  friends.  The  abject 
terror  and  demoralization  on  the  part  of  the  patient  is  due  to  the  fact 
that  it  is  not  infrequently  tlie  first  flat  argument  that  he  has  tubercu- 
losis, and,  again,  the  source  of  the  hemorrhage  makes  it  plain  to  the 
average  patient  that  not  only  he,  but  his  physician,  are,  in  a  sense,  at 
its  mercy.  Fortunately,  no  incipient  and  few  advanced  cases  of  tuber- 
culosis die  from  the  immediate  effects  of  hemorrhage.  Before  cavity 
formation  the  hemorrhage  is  bronchial.  After  this  it  comes  from  the 
erosion  of  a  blood-vessel  or  the  bursting  of  an  aneurysm ;  the  result  will 
depend  on  the  size  of  the  vessel  that  ruptures.  Considering  the  preva- 
lence of  tuberculosis  and  its  destructive  process  in  the  lungs,  it  is  singu- 
lar that  so  few  patients  die  from  hemorrhage.  In  rare  cases,  with  enor- 
mous cavities,  patients  have  been  known  to  bleed  to  death  with  little 
or  no  blood  appearing  in  the  expectoration. 

In  cases  of  pulmonary  hemorrhage  my  practice  is  uniform,  and  no 
information  which  our  present  methods  of  physical  examination  give 
is  suflficient  to  make  me  change  it,  for  the  very  good  reason  that  we 
have  no  means  of  telling,  aside  from  the  amount  of  blood  that  comes 
up,  the  size  of  the  vessel  that  has  ruptured.  I  have  seen  a  patient 
who  had  a  cavity  apparently  no  larger  than  a  walnut  practically  ex- 
sanguinated by  the  excessive  loss  of  blood.  On  the  other  hand,  in  cases 
with  enormous  cavities,  the  hemorrhage  is  oftentimes  small.  There  is, 
then,  no  infallible  index,  and  when  the  hemorrhage  is  taking  place,  even 
the  sojirce  is  immaterial,  for  whatever  its  source,  outside  of  strapping 
the  chest  to  restrict  its  movements  the  indications  for  treatment  are 
the  same. 

These  consist  of  the  following:  Absolute  rest  in  bed,  with  the 
body  elevated  by  pillows  so  as  to  let  gravity  act  as  little  as  possible. 
The  patient  should  make  no  active  exertion  whatever.  If  tlie  hemor- 
rhage is  excessive  the  blood  should  be  caught  by  an  attendant,  who 
holds  a  basin  under  the  chin  of  the  ])atient.  After  this,  when  the 
hemorrhage  is  less  active,  the  blood  should  be  caught  in  a  cloth,  but 
the  patient  should  not  have  to  do  this  for  himself.    His  position  in  bed 


632      HOME  TREATMENT  BY  SANATORIUM  METHODS 

should  be  changed  as  little  as  possible,  and  he,  of  course,  should  not 
be  allowed  to  talk  or  rise  from  his  bed,  even  to  attend  to  the  wants 
of  nature.  It  is  a  safe  plan  to  keep  all  patients  in  bed  for  at  least 
three  days  after  the  hemorrhage,  and  even  then  exercise  should  be 
resumed  very  gradually. 

Aside  from  the  imposition  of  absolute  and  immediate  rest,  the  first 
indication  on  the  appearance  of  a  hemorrhage  is  a  hypodermic  injection 
of  morphin.  I  usually  give  \  grain,  as  I  believe  that  ordinarily  less  does 
not  accomplish  the  purpose.  In  those  cases  in  which  this  amount 
causes  the  blood  accumulation  to  strangle  the  patient,  as  is  claimed  by 
some,  I  believe  that,  if  left  to  flow  freely,  it  will  more  quickly  exsan- 
guinate him.  In  other  words,  I  believe  that  our  only  hope  in  pulmo- 
nary hemorrhage  is  the  clotting  of  the  blood  so  as  to  heal  up  the  broken 
vessel  by  pressure.  Morphin  effects  this  ])y  quieting  the  respiratory 
movements,  checking  the  cough  and  obtunding  the  sensibilities  of  the 
patient.  It  is  perfectly  legitimate  to  argue  that  the  hemorrhage  may 
be  of  such  a  degree  as  to  drown  the  patient  in  his  own  blood  if  it  is 
pent  up  in  the  lungs;  on  the  other  hand,  it  seems  to  me  to  be  equally 
true,  in  the  first  place,  that  a  hypodermic  of  morphin  wliich  does  not  put 
the  patient  into  a  stupor  is  not  going  to  accomplish  this,  and  in  the 
second  place,  if  the  flow  is  not  checked  by  a  certain  amount  of  reten- 
tion of  blood,  the  patient  will  surely  bleed  to  death.  The  morphin  also 
steadies  and  acts  as  a  tonic  to  the  heart.  It  goes  without  saying  that 
the  dose  of  mor])liin  must  be  regulated  by  the  age,  size,  physical  condi- 
tion and  idiosyncrasies  of  the  patient.  It  should  he  repeated  sufficiently 
often  to  control  his  cough  and  nervous  perturbation. 

After  the  immediate  demands  are  met,  the  same  effects  may  be 
obtained  by  the  administration  of  appropriate  doses  of  heroin,  codein, 
or  morphin  by  the  mouth.  However,  it  is  preferable  to  abstain  from 
any  medication  that  is  apt  to  upset  the  stomach,  as  emesis  would  tend 
to  increase  or  renew  the  hemorrhage.  It  is  well  also  not  to  attempt 
to  give  any  solid  food  for  twenty-four  hours.  If  the  hemorrhage  has 
been  severe,  an  enema  of  salt  solution  or  a  hypodermoclysis  will  produce 
a  more  immediate  effect  than  food  introduced,  often  through  protest  and 
with  difficulty  into  the  stomach. 

There  can,  of  course,  be  no  objection  to  giving  egg  albumen  in  the 
water  that  is  often  craved  in  large  quantities.  Milk  may  be  given  in 
place  of  water.  It  is  common  for  patients  having  a  hemorrhage,  from 
such  information  as  they  may  have,  or  on  the  advice  of  solicitous  friends, 
to  eat  salt.  It  serves  to  occupy  the  attention  of  the  patient,  but  its 
effect  on  the  hemorrhage  is  infinitesimal,  while  by  deranging  the 
stomach  it  may  cause  vomiting,  which,  as  has  already  been  stated,  is  bad. 

From  its  effect  in  uterine  hemorrhage  ergot  has  been  employed  as 


SYMPTOMATIC  TREATMENT  *  633 

a  routine  practice  in  pulmonary  hemorrhage.  Confidence  in  it,  with 
added  experience,  is  wavering.  I  have  never  seen  it  accomplish  any 
good  whatever  in  pulmonary  hemorrhage,  and,  indeed,  some  observers 
claim  that  it  does  harm.  What  applies  to  ergot  applies  with  equal  force 
to  its  preparations,  ergotin  and  ergotole.  It  is  probably  also  true  that 
tannic  and  gallic  acid  not  only  fail  to  do  good,  but  serve  to  derange 
the  stomach. 

From  a  scientific  standpoint  calcium  chlorid,  by  increasing  the  coag- 
ulative  power  of  the  blood,  would  seem  a  rational  remedy  to  use.  It 
may  be  given  in  doses  of  5  to  15  grains,  three  or  four  times  a  day.  It 
should  be  used  more  generally  and  its  effects  more  carefully  noted. 
Gelatin  has  been  employed  in  somewhat  the  same  way  in  an  effort  to 
increase  the  coagulability  of  the  blood. 

From  a  purely  empyric  standpoint,  perhaps,  some  of  the  prepara- 
tions of  the  suprarenal  body  are  being  used  as  remedies  in  pulmonary 
hemorrhage.  For  the  past  four  or  five  years  I  have  employed  them, 
along  with  opium,  in  all  my  cases  of  pulmonary  hemorrhage.  It  may 
be  difficult  to  explain  from  a  physiologic  standpoint  just  how  it  may  be 
expected  to  control  hemorrhage  from  the  pulmonary  vessels.  In  the 
absence  of  a  satisfactory  explanation,  my  experience  still  leads  me  to 
rel}'  on  it  in  this  condition.  I  usually  employ  5  drops  of  adrenalin 
chlorid,  or  3  grains  of  the  suprarenal  extract,  every  three  or  four  hours, 
while  the  hemorrhage  persists  or  the  sputum  is  bloody. 

So  far  as  we  know,  adrenalin  inhibits  hemorrhage  by  vasoconstric- 
tion. It  is  proved  that  it  increases  vascular  tension  by  its  vasocon- 
striction effect.  If  w«  had  only  this  evidence  we  would  not  use  it  even 
in  epistaxis,  as  by  increasing  the  pressure  in  the  blood-vessels  it  gives 
additional  power  to  wash  away  any  clots  that  might  form  to  seal  up 
the  vessels.  Clinically,  however,  we  know  that  it  is  the  most  reliable 
medicinal  agent  we  possess  for  checking  hemorrhage,  with  the  possible 
exception  of  the  perchlorid  of  iron,  and  this  is  rarely,  if  ever,  employed 
because  of  its  disagreeal^le  local  eil'ect. 

If  the  extract  of  tiie  suprarenal  gland  controls  hemorrhage  that  is 
accessible,  it  may  have  tlie  same  effect  also  on  tliat  which  is  not.  In 
any  event,  it  is  recommended  in  cases  of  hemorrliage  in  typhoid  and 
in  uterine  hemorrhage,  and  I  see  no  reason  why,  if  it  acts  well  in  these 
cases,  it  should  not  also  be  efficient  in  pulmonary  hemorrhage. 

From  a  physiologic  standpoint,  the  nitrites  have  a  diametrically 
opposite  action,  producing  vasodilation.  They  diminish  intra-arterial 
tension.  This  produces  less  pressure  on  the  break  in  the  vascular 
mechanism  and  allows  the  coagulum  more  quickly  to  close  the  opening. 
This  has  led  to  the  use  of  nitrite  of  amyl,  which,  because  of  its  dif- 
fusibility,  is  usually  dispensed  in  glass  globules,  one  of  which  may  be 


634      HOME  TREATMENT  BY  SANATORIUM  METHODS 

broken  in  a  handkerchief  and  inhaled  as  occasion  demands.  More  com- 
monly nitroglycerin  is  used^  either  hypodermically  when  the  hemor- 
rhage is  taking  place,  or  by  mouth  to  prevent  its  recurrence.  The  dose 
ranges  from  y^  to  -g\  grain,  repeated  as  occasion  demands.  When  un- 
due flushing  of  the  face  and  headache  result,  it  is  the  signal  that  the  dose 
should  be  diminished  or  the  drug  withheld.  N.  A.  Johnson  and  R.  H. 
Babcock  recommend  hypodermics  of  atropin  immediately  on  the  appear- 
ance of  the  hemorrhage,  in  doses  of  -jV  to  -g^  grain. 

When  the  intravascular  pressure  is  great,  the  pulse  rapid  and  Ijound- 
ing,  and  a  marked  accentuation  of  the  second  heart  sound  exists,  nitro- 
glycerin may  be  employed.  Flick  believes  that  it  not  only  diminishes 
hemorrhage,  but  that  it  prevents  the  development  of  hemorrhage.  In 
extreme  conditions  j^o  grain  every  two  hours  may  be  given.  Nitro- 
glycerin possesses  two  advantages  that  should  be  considered.  It  lowers 
arterial  tension  and  increases  the  secretion  of  urine.  Sodium  nitrite 
(3  to  5  grains)  three  or  four  times  a  day  may  be  substituted  for  nitro- 
glycerin, and  is  said  to  have  a  more  permanent  effect. 

The  vascular  system  may  be  depleted  by  the  exliibition  of  salts. 
Their  employment, is  indicated  for  the  same  reason  as  are  the  nitrites, 
but  their  action  is  not  so  immediate  and  the  additional  drawback  to  their 
use  is  found  in  the  exertion  which  active  purgation  enforces  on  the 
patient.  While  salts  may  be  rationally  employed  after  the  hemorrhage 
has  abated,  I  rarely  prescribe  them  inside  of  twenty-four  hours  of  an 
active  hemorrhage. 

I  speak  lastly  of  the  application  of  the  ice-bag,  because,  as  already 
mentioned,  the  source  of  the  hemorrhage  is  not  always  accurately  known, 
and  while  the  hemorrhage  is  taking  place  it  is  unwise  to  try  to  find  it; 
and  to  be  more  than  generous  in  our  estimate,  it  is  of  questionable  value. 
It  quiets  the  tumultuous  activity  of  the  heart,  and  in  so  far  may  do 
good,  but  I  do  not  believe  that  it  has  any  effect  on  the  bleeding  vessels. 
If  it  is  of  such  questionable  benefit,  and  the  same  results  may  be  ob- 
tained by  other  more  promising  measures,  I  see  no  good  reason  for  its 
employment. 

When  the  hemorrhage  is  excessive  the  emergency  may  be  tided  over, 
and  the  patient's  life  sometimes  saved  by  keeping  the  blood  in  the 
extremities  by  means  of  a  constricting  band  of  rubber  tubing  or  other 
form  of  tourniquet;  these  should  be  released  successively  so  as  to  let 
the  blood  into  the  general  circulation  and  to  avoid  the  formation  of 
clot  and  subso(|uoiit  gangrene  of  the  extremities.  In  extreme  cases  the 
elevation  of  the  foot  of  tlie  bed  and  hypodermoclysis  may  be  necessary. 

Cardiac  Weakness  and  Dyspnea. — The  destructive  metamorphosis 
which  is  general  tiiroughout  tlie  nnisculature  of  the  body  is  also  present 
in  the  heart;  tlie  heart  muscle  gets  weak  and  flal)by  and  dyspnea  be- 


COMPLICATIONS  635 

comes  a  distressing  s3'mptom.  In  addition  to  the  general  and  cardiac 
muscular  weakness  in  producing  dyspnea,  we  must  also  consider  the 
effect  produced  by  the  destruction  of  lung  tissue  and  the  toxic  effect 
of  the  poisons  absorbed.  The  last  is  well  illustrated  in  the  dyspnea  that 
accompanies  excessively  high  fever.  In  combating  the  condition  which 
is  at  times  most  distressing,  one  should  look  to  two  ends,  viz. :  the 
general  treatment  of  the  underlying  condition  which  is  producing  the 
trouble,  and  the  immediate  alleviation  of  the  urgent  symptoms.  Gradu- 
ated massage  and  exercise,  an  abundance  of  food  and  fresh  air  will, 
by  improving  the  general  condition,  alleviate  some  cases,  but  the  ma- 
jority of  cases  require  absolute  rest  in  bed. 

In  this  condition  strychnin  is  almost  always  indicated,  and  it  may 
be  given  in  larger  doses  than  are  ordinarily  employed.  Tincture  of 
digitalis  (gtt.  15)  three  times  daily  or  every  four  hours  is  a  remedy  of 
the  greatest  value.  Alcohol  in  generous  quantities  should  be  admin- 
istered. The  rapidly  diffusible  stimulants,  such  as  aromatic  spirits  of 
ammonia,  Hoffman's  anodyne,  or  a  solution  of  camphor  in  oil,  either 
by  mouth  or  hypodermically,  may  be  employed  in  appropriate  cases. 

In  some  cases  the  inhalation  of  oxygen  gas  will  give  the  greatest 
temporar}'^  relief.  Finally,  when  the  dyspnea  is  excessive  and  the  dis- 
tress of  the  patient  great,  the  effect  of  the  hypodermic  injection  of  ^ 
grain  of  morphin  is  almost  magical.  Considering  the  amount  of  lung  tis- 
sue destroyed  and  the  toxic  processes  at  work,  it  is  singular  that  we  do 
not  have  this  distressing  symptom  oftener. 

COMPLICATIONS 

The  more  common  complications  of  tuberculosis  are  pneumonia,  in- 
somnia, pain,  pleurisy,  both  with  and  without  effusion,  empyema,  pneu- 
mothorax, jiityriasis  versicolor,  ischiorectal  abscess,  and  fistula  in  ano. 
The  treatment  of  pneumonia  complicating  tuberculosis  does  not  differ 
from  that  complicating  other  diseases. 

Insomnia. — In  dealing  with  insomnia  in  tuberculous  patients,  the 
same  rule  should  guide  us  as  in  treating  tlie  proper  symptoms  of  the 
trouble,  give  as  little  medicine  as  possible.  In  some  cases  allaying  the 
cough,  or  in  others  checking  the  night  sweats,  may  do  away  with  the 
insomnia.  A  glass  of  hot  milk  taken  at  bedtime,  or  milk  to  which 
whisky  or  cognac  brandy  has  been  added,  will  make  the  patient  fall  into  a 
tranquil  sleep. 

When  drugs  must  be  employed,  those  which  disturb  digestion  least 
should  l)e  used.  I  have  found  veronal,  trional,  and  sulphonal  to  fulfill 
this  condition  and  to  produce  a  sleej)  more  closely  akin  to  nature's  sleep 
than  any   otiiei-  liy})notics.     Veronal   is  usually  given   in   .l-grain  doses 


iiS o^s;       15 


636  HOME   TREATMENT   BY   SANATORIUM   METHODS 

in  capsule.  Trional  and  sulphonal  are  best  administered  in  a  powder 
or  cachet.  Ten  to  15  grains  are  usually  given  at  a  dose,  and  should 
immediately  be  followed  by  a  cupful  of  milk  or  water,  as  hot  as  can 
comfortably  be  swallowed.  This  hastens  and  increases  the  effect  of  the 
drug.  In  cases  with  much  nervous  disturbance  I  have  found  the  fol- 
lowing prescription  especially  efficacious,  particularly  when  there  is 
present,  in  addition,  the  so-called  nervous  cough : 

I^   Sodii  bromidi   5j  5         30  gm. 

Spiritus  ammonii   aromatici, 

Spiritus  lavandulae  comp., 

Essence  pepsini qIv  ;     130    " 

M.     Sig. :  One  drachm  to  two  drachms  in  water  at  bedtime. 

Instead  of  the  above,  chloralamid  (10  grains)  may  be  administered 
on  retiring.  Naturally  opium,  in  some  of  its  preparations,  or  cannabis 
indica  will  produce  the  same  result,  but  they  should  only  be  given  when 
the  other  remedies  mentioned  have  failed. 

Fain. — When  pain  in  the  chest  occurs  in  tuberculosis,  its  cause 
should  be  sought  for  and  ascertained.  The  treatment  of  muscular  pains 
and  neuralgias  does  not  differ  essentially  from  that  employed  in  other 
diseases.  When  the  pain  is  pleuritic,  it  may  be  alleviated  by  external 
applications — e.  g.,  mustard  plasters,  tincture  of  iodin,  dry  cupping, 
etc.,  over  the  affected  area,  or  hot-Avater  stupes,  poultices,  hot-oil  com- 
presses, etc.  In  a  majority  of  cases,  strapping  the  chest  on  the  affected 
side  with  strips  of  adhesive  plaster  will,  by  limiting  the  respiratory 
excursions,  bring  relief.  In  some  cases  it  will  be  found  advisable  to 
administer  sodium  salicylate  (5  to  10  grains)  three  times  daily,  or  phe- 
nacetin  (5  grains)  repeated  in  three  or  four  hours,  if  necessary.  Occa- 
sionally a  h3'podermic  of  morphin  (^  grain)  or  codein  (^  grain)  may  be 
necessary. 

Pleurisy  with  Effusion. — When  there  is  pleurisy  with  effusion,  when 
the  fluid  accumulation  is  sufficient,  the  pleuritic  pains  subside  spon- 
taneously. In  order  to  get  rid  of  the  exudate,  the  amount  of  fluid 
ingested  should  be  cut  down  to  the  minimum,  and  the  activity  of  the 
kidneys  increased.  For  this  purpose  nitroglycerin  (yi^  to  -^^  grain) 
and  infusion  of  digitalis  (jss)  every  four  hours  may  be  given;  or  it  may 
be  necessary  to  add  to  the  above  acetate  of  potassium  or  sodium  (20 
to  30  grains),  the  object  being  to  make  the  amount  of  liquid  excreted 
greater  than  that  which  is  drunk. 

If  this  cannot  be  done,  then  resort  must  be  had  to  the  aspirating 
needle.  If  paracentesis  of  the  thorax  is  undertaken  it  should  be  done 
under  the  strictest  aseptic  precautions,  otherwise  a  serous  pleurisy  will 
be  converted  into  a  purulent  pleurisy. 


COMPLICATIONS  637 

In  performing  paracentesis  the  skin  should  be  cleansed  thoroughly 
with  green  soap,  alcohol,  and  ether  at  the  point  where  the  needle  is  to 
be  inserted,  which  should  be  between  the  eighth  and  ninth  ribs,  in  a 
line  with  the  angle  of  the  scapula,  or  in  the  seventh  interspace,  in  the 
midaxillary  line.  The  needle  should  be  thoroughly  sterilized  by  boiling, 
and  should  be  inserted  close  to  the  margin  of  the  lower  rib,  as  in  this 
way  one  will  avoid  wounding  the  intercostal  artery  which  runs  in  the 
groove  beneath  the  rib  above. 

Local  anesthesia  of  the  part  may  be  obtained,  if  desired,  by  the 
hypodermic  use  of  cocain,  by  freezing  the  area  either  with  an  ethyl 
chlorid  spray  or  by  the  application  of  ice.  The  intercostal  space  may  be 
widened  by  placing  the  hand  of  the  affected  side  on  the  opposite  shoul- 
der. The  fluid  may  be  withdrawn  simj^ly  with  a  needle,  to  which  a 
long  tube  is  attached,  thus  siphoning  it  off,  or  the  tube  may  be  attached 
to  a  bottle  in  which  a  partial  vacuum  is  produced  by  a  pump  and  the 
fluid  thus  sucked  out.  In  large  effusions  too  much  fluid  should  not 
be  withdrawn  at  one  time,  as  the  too  sudden  removal  of  pressure  on  the 
heart  and  vessels  has  led  to  serious  consequences.  Wlien  the  patient  com- 
plains much  of  faintness,  or  violent  coughing  ensues,  it  is  well  to  desist. 

After  withdrawing  the  needle  the  aperture  in  the  skin  should  imme- 
diately- be  closed  by  a  strip  of  adhesive  plaster. 

Empyema. — In  the  case  of  empyema  the  pus  should  be  removed  as 
soon  as  the  diagnosis  is  made.  In  the  majority  of  cases  this  may  be 
effected  by  making  a  free  incision  in  the  midaxillary  line  l)etween  the 
sixth  and  seventh  ribs  and  introducing  a  drainage-tu])e.  In  some  cases 
the  space  between  the  ribs  is  too  narrow  to  admit  a  drainage-tube  of 
sufficient  size.  Then  two  or  more  ribs  must  be  resected  (Estlander's 
operation). 

Pneumothorax, — In  pneumothorax,  rest  in  bed  and  strapping  the 
chest  are  to  be  recommended.  Stimulants  will  be  necessary  when  faint- 
ness and  collapse  are  present.  Wlien  much  coughing  and  dyspnea  occur, 
a  hypodermic  of  morphin  (I  grain)  is  indicated. 

Pityriasis  versicolor. — Pityriasis  versicolor  is  a  harmless  though 
troublesome  symptom  which  occurs  in  tuberculosis.  It  may  be  dis- 
tributed, more  or  less,  over  the  entire  body,  the  spots  and  bleblike  ele- 
vations varying  in  size  from  a  small  shot  to  a  split  pea.  It  may  read- 
ily be  relieved  by  washing  the  skin  with  castile  soap  and  warm  water, 
sponging  in  vinegar  or  dilute  acetic  acid,  and  afterwards  with  a  drachm 
of  sodium  hyposulphite  to  the  ounce  of  water.  Tliree  applications  of 
this,  according  to  Latham,  are  usually  sufficient. 

Ischiorectal  Abscess. — Ischiorectal  abscess  occurs  not  infrequently  in 
advanced  stages  of  tlie  disease  as  does  also  its  companion,  fistula  in  ano. 
The  treatment  is  entirely  surgical. 


638      HOME  TREATMENT  BY  SANATORIUM  METHODS 

Tuberculous    Laryngitis. — Tuberculous    involvement   of    the    larynx 

and  ejjiglottis  is  one  of  the  most  serious  and  at  the  same  time  distress- 
ing complications  of  tuberculosis.  For  its  relief  the  same  general 
regime  of  fresh  air,  feeding,  rest,  etc.,  is  demanded.  In  addition,  local 
treatment  of  the  affected  area  must  be  carried  out.  Nowhere  is  the 
effectiveness  of  rest  better  proved  than  here.  The  patient  should  not  be 
allowed  to  talk  at  all ;  even  loud  whispering  is  to  be  avoided.  In  mak- 
ing his  wants  known  the  deaf  and  dumb  sign  language  or  a  Vv^riting 
tal)let  should  be  used. 

As  a  local  application,  a  ten-per-cent  solution  of  argyrol  may  be 
applied  to  the  vocal  chords  once  daily  or  they  may  be  paintx^-d  with  a 
solution  of  equal  parts  of  tincture  of  iodin  and  glycerin,  to  which  ten 
grains  of  potassium  iodid  have  been  added.  Much  relief  will  also  be 
afforded  by  the  use  of  the  following  oil  s])ray,  the  patient  taking  deep 
inhalations  the  while: 

^  Mentholi    gr.  xx ;        1.3.3  gm. 

Camphor;!^    gr.  v ;  0.31?    " 

Acidi  carbolic i    gr.  vj  :  0.40    " 

Eucalyptoli gtt.  iij ;  0.-?0    " 

Glymoli ^ij ;  60.00    " 

M.     Sig. :  Use  in  atomizer^  p.  r.  n. 

When  ulceration  of  the  chords  exists,  Heryng  and  Krause  recom- 
mend painting  or  gentle  rubbing  of  the  ulcers  witii  lactic  acid,  30  to 
80  per  cent,  once  or  twice  a  day,  if  too  great  distress  is  not  caused; 
or  Lake's  pigment  (lactic  acid,  50  per  cent;  formalin,  7  per  cent;  car- 
bolic acid,  10  per  cent).  Deeper  ulcers  require  curettement  and  electrol- 
ysis. Insufflations  of  iodol,  aristol,  and  orthoform  are  also  employed. 
Prior  to  the  application  of  these,  it  is  frequently  desirable  to  cleanse 
the  parts  with  an  antisei)tic  sj)ray — e.g.,  Dobell's  solution. 

If  much  edema  of  tlie  glottis  exists,  scarification  may  give  some 
relief.  In  this  condition  the  writer  has  gotten  satisfactory  results  from 
the  application  of  suprarenal  extract  with  chloretone  or  adrenalin  chlo- 
rid.  It  acts  in  the  same  way  here  as  it  does  in  opening  up  a  nose  that 
is  closed  by  a  congested  mucous  membrane.  It  has  not  the  anesthetic 
properties  of  cocain,  but  it  possesses  two  advantages  that  cocain  has  not 
— its  effects  last  longer  by  several  hours,  and  in  addition  it  does  not 
derange  the  digestion.  In  severe  cases  it  may  even  be  combined  with 
cocain. 

When  the  ulceration  is  marked  and  the  edema  great,  the  patient 
reaches  a  point  where  proper  nourishment  is  a  serious  matter,  not  only 
on  account  of  the  difficulty  in  swallowing,  but  also  because  of  the  pain 


COMPLICATIONS  639 

and  l)ecause  tlie  swollen  and  enlarged  epiglottis  does  not  close  down 
pro]>erly,  thus  allowing  food  to  go  into  the  trachea,  causing  violent 
coughing  and  sufi'ocation.  By  painting  the  area  with  suprarenal  extract 
and  following  this,  if  necessary,  by  the  application  of  a  four-per-cent 
solution  of  eocain,  much  comfort  will  be  given  the  patient  and  he  will 
more  readily  take  the  necessary  amount  of  food. 

Sometimes  his  food  will  have  to  be  administered  through  a  stomach- 
tube,  and  in  some  cases  even  the  passage  of  the  stomach-tube  is  intol- 
erable, and  resort  will  have  to  be  had  to  rectal  feeding. 

In  extreme  cases,  with  marked  dyspnea,  tracheotomy  will  have  to 
be  performed. 

Diarrhea. — Diarrhea  occurring  in  the  course  of  tuberculosis  may  be 
the  result  of  indiscretions  in  dietj  of  irritation  by  foodstuffs,  which, 
though  not  of  necessity  indigestible,  still  from  impaired  digestive  activ- 
ity are  not  assimilated,  act  as  irritants  to  the  digestive  tract.  On  the 
other  hand,  the  diarrhea  may  arise  from  tuberculous  ulceration  of  the 
intestine.  Tlie  latter  necessarily  causes  the  greater  ditficulties,  and  at 
times  is  utterly  beyond  our  control.  In  either  case  it  is  best  to  rid 
the  alimentary  tract  of  any  indigestible  food  residue  that  may  be  pres- 
ent. For  this  purpose  it  is  well  to  give  calomel  in  ^-grain  doses  every 
half  hour  until  2  or  3  grains  are  taken.  This  should  be  followed 
by  a  brisk  saline  laxative,  or,  in  some  cases,  castor  oil.  Xaturall)',  the 
diet  must  be  regulated  and  only  such  food  as  is  easily  digested  should 
be  allowed.  Bismuth  should  be  given  in  some  form,  either  the  sub- 
nitrate  (30  to  GO  grains),  the  subgallate  (10  grains),  or  the  salicylate 
(5  grains),  every  four  or  six  hours,  with  opium,  either  the  powdered 
extract  (5  to  4  grain),  codein  (|  grain),  paregoric  (1  to  2  drachms),  or 
Dover's  powder  (3  to  5  grains),  and  repeated  as  occasion  demands.  In 
some  cases  tannalbin   (10  to  15  grains)  will  be  of  service. 

When  the  discharges  are  excessive  I  have  obtained  good  results  from 
bismuth. 

I^   Tincture  catechu  comp.,  "j 

Tincture  opii,  v  aa oijss ;     10  gm. 

Spiritus  camj)hora\  j 

M.     Sig. :  30  to  40  drops  every  four  hours. 

Francine  recommends  tlie  following,  as  modified  from  Osier: 

I^   Plumbi  acetatis   oj ;  4  gm. 

Acidi  acetici  dil 3Jss;       6    " 

Syrupi  simplicis   oiij ;  12    " 

Aqua  cinnamoni    ad  ,^iij ;  90    " 

M.     Sig.:  A  teaspoonful  three  or  four  times  a  day. 


640    THE   SANATORIUM,    ITS   CONSTRUCTION   AND    MANAGEMENT 


THE  SANATORIUM,   ITS  CONSTRUCTION  AND  MANAGEMENT 
By   ARNOLD   C.   KLEBS 

In  the  foregoing  paragraphs  the  hygienic  treatment  of  tuberculosis 
has  been  discussed  without  particular  reference  to  special  institutions, 
wherein  its  details  have  been  elaborated.  Although  these  details  are  per- 
haps not  of  distinct  interest  to  the  general  practitioner,  they  cannot  fail 
to  be  suggestive  in  many  ways,  and  particularly  to  those  who  are  con- 
templating, as  seems  most  desirable,  the  erection  of  smaller  sanatoria 
throughout  the  country. 

The  term  "sanatorium"  (sanarc,  to  heal)  presupposes  the  cura- 
bility of  the  patients  whom  it  is  destined  to  receive.  It  is  not  merely 
a  "sanitarium''  (sanitas,  health),  a  health  resort,  an  institution  for 
the  reception  of  the  sick,  no  matter  what  their  chances  for  cure.  This 
refinement  of  terminology  is  perhaps  somewhat  artificial,  but  the  tend- 
ency of  late  years  lias  been  to  call  sanatoria  those  institutions  which 
admit  for  treatment  only  patients  in  the  early  stages  of  the  disease, 
in  contradistinction  to  the  hospitals  which  are  open  to  any  class  of  cases. 

At  one  time,  especially  through  the  influence  of  German  propa- 
ganda, the  sanatorium  occupied  the  center  of  the  stage  in  antitubercu- 
losis efforts.  For  the  individual  as  well  as  for  the  State  all  hope 
was  concentrated  in  the  erection  of  such  institutions.  A  clearer  con- 
ception of  its  true  position,  through  a  more  precise  application  of  experi- 
ence, has  been  gained  of  late.  First  of  all  it  has  been  realized  that 
in  order  to  accomplish  a  complete  and  lasting  cure  a  longer  sojourn 
of  patients  in  the  sanatorium  than  customary  (three  to  four  months)  is 
necessary,  and  on  the  other  hand  that  this  longer  sojourn  has  disadvan- 
tages in  itself,  in  so  far  as  it  very  often  mentally  disables  the  discharged 
patient  for  his  former  pursuits.  Considerations  of  this  kind  have 
called  forth  of  late  unnecessarily  violent  attacks  against  the  sanatorium 
(Cornet,  '07),  disclaiming  all  its  merits,  at  least  for  the  treatment  of 
persons  of  slender  means.  That  such  wholesale  condemnation  goes  too 
far  can  be  easily  demonstrated,  and,  in  explanation  of  it,  it  can  only 
be  said  that  it  is  directed  more  against  a  special  system  as  practiced 
in  Germany,  than  against  the  principle  itself  of  treatment  in  closed 
institutions.  But  this  fight,  pro  and  con  sanatoria,  has  brought  forth 
object  lessons  which  those  who  are  planning  the  construction  of  sana- 
toria will  do  well  to  examine  more  closely. 

Brehmer,  in  Gorbersdorf,  and  later  his  pupil,  Dettweiler,  in  Falken- 
stein,  by  demonstrating  the  curability  of  tuberculosis  by  means  of 
statistics  of  cases  treated  by  hygienic-dietetic  methods  in  their  institu- 


THE  SAXATORIUM,  ITS  CONSTRUCTION  AND  MANAGEMENT   641 

tions,  started  not  only  an  era  of  greater  hopefulness  in  phthisio-tliera- 
peuties,  but  elevated  the  method  itself  to  the  position  it  now  maintains. 
There  was  nothing  particularly  new  in  the  method;  as  early  pioneers 
in  it  must  be  named  Andrew  Stewart,  of  Erskine,  Scotland  (17-i7), 
William  Buchan  (1783),  our  own  Benjamin  Eush  (179-1),  and  especially 
George  Bodington,  of  Sutton  Coldiield,  Warwickshire,  England,  who 
had  practiced  it  successfully  before  Brehmer  and  Dettweiler,  but  the 
credit  for  systematic  application  on  a  large  scale  and  demonstration  of 
tlie  results,  followed  by  a  more  general  adoption,  cannot  be  denied 
them.  Typical  of  the  German  system,  as  we  may  call  it,  is  the  minute 
and  individual  application  of  hygienic  principles  under  close  and  per- 
sistent supervision  of  the  physician  in  an  especially  constructed  insti- 
tution. They  were  regarded  more  as  schools  of  hygienic  discipline,  with 
little  left  to  the  patient's  initiative  except  strict  obedience.  Differences 
in  national  traits  have  long  hindered  the  introduction  of  the  system  into 
other  countries  or  have  brought  about  modifications.  Its  paramount 
value  as  exemplified  by  its  good  results,  has  spread  the  sanatorium  gospel 
all  over  the  world,  and  although  it  cannot  be  said  to  have  everywhere 
the  same  meaning  as  to  details,'  its  range  of  activity  and  its  position 
among  other  curative  agencies,  as  well  as  its  limitations,  are  pretty  well 
realized.  It  is,  however,  becoming  more  and  more  apparent  that  the 
sanatorium  in  its  present  stage  of  evolution  does  not  fulfill  all  the 
desiderata  of  institutional  treatment,  that  it  needs  to  be  supplemented 
by  other  institutions  and  amplified  in  its  scope;  also  that  the  home 
treatment  on  sanatorium  lines  allows  perfections  not  thought  possible 
only  a  few  years  ago.  If  credit  must  be  given  to  the  great  Germans, 
Brehmer  and  Dettweiler,  for  having  successfully  launched  the  sys- 
tematic, hygienic,  and  dietetic  treatment  in  institutions,  the  elaboration 
of  it  has-been  done  in  other  countries,  particularly  in  England  and 
America.  The  greatest  impetus  to  English  sanatorium  evolution,  how- 
ever, came  from  another  German,  Walthcr,  who  in  his  Xordrach  colony 
in  the  Black  Forest  practiced  the  method  on  lines  more  sympathetic 
to  an  English  public  than  those  of  Goerbersdorf  and  Falkenstein.  In 
our  own  country,  Edward  Trudeau  is  the  undisputed  pioneer  and  leader 
in  sanatorium  work.  Since  1873,  when  he  was  sent  to  the  Adirondack 
Mountains  as  a  patient,  lie  evolved  there,  stage  by  stage,  one  of  the 
most  admirable  centers  for  the  treatment  of  tuberculosis  on  hygienic- 
dietetic  lines,  and  one  which  has  been  for  a  long  time  the  sole  inspira- 
tion for  similar  enterprises  on  this  side  of  the  Atlantic. 

Requisites  of  the  Sanatorium. — An  absolute  and  definite  standard 
of  requisites  for  a  sanatorium  cannot  be  laid  down.  Sanatoria  have 
been  constructed  in  all  kinds  of  climates,  after  plans  differing  in  many 

details  and  at  an  expenditure  varying  from  a  few  hundred  dollars  per 
42 


642    THE  SANATORIUM,   ITS   CONSTRUCTION  AND   MANAGEMENT 

bed  to  several  thousand  dollars.  In  location  and  in  construction  the 
sanatorium  has  to  adapt  itself  to  individual  requirements,  the  financial 
resources  and  the  number  of  patients  it  is  to  receive.  The  vast  majority 
of  candidates  for  the  sanatorium,  however,  belong  to  a  class  which  has 
to  consider  carefully  every  item  of  expenditure,  particularly  so  in  a 
disease  of  so  chronic  a  course,  which  is  bound  to  make  heavy  demands 
on  all  available  resources  for  a  long  time  to  come.  It  is  an  important 
duty  of  the  family  physician  to  impress  this  fact  upon  his  patients  and 
not  allow  them  to  stake  their  last  penny  upon  this  one  card,  the  sana- 
torium, in  the  belief  that  the  regained  health  after  a  few  months' 
treatment  will  permit  their  resuming  without  restraint  their  former 
occupation.  Future  sacrifices  will  be  absolutely  necessary  in  most  cases 
to  maintain  the  improvement  made.  It  is  also  evident  that  a  multi- 
plication of  sanatoria  is  most  desirable.  Especially  in  this  country, 
sanatorium  treatment  for  those  classes  most  in  need  of  it  is  wholly 
inadequate.  In  Germany,  where,  very  largely  through  the  provision  of 
an  invalidity  insurance  system,  large  funds  are  available  for  the  build- 
ing and  maintenance  of  sanatoria,  such  a  multiplication  has  been  dis- 
tinctly furthered.  We  have  no  such  system  and  are  chiefly  dependent 
on  individual  resources,  charitable  aid,  and  to  some  extent  on  State  and 
municipal  initiative.  The  various  State  sanatoria  now  in  operation  in 
this  country  have  given  a  distinct  impetus  to  the  movement  and  it  is 
much  to  be  hoped  that  municipalities  will  also  awaken  to  the  exigencies 
of  the  situation  and  provide  sanatoria  for  the  numerous  sick,  which 
cannot  find  admittance  in  the  State  institutions. 

If  a  general  standard  cannot  be  laid  down  for  sanatoria  and  is  not 
even  desirable,  as  was  well  pointed  out  recently  by  Bulstrode  ('08), 
because  of  its  hampering  individual  experiments,  certain  definite  guid- 
ing principles  ought  to.be  before  those  interested  in  the  construction 
of  sanatoria.  They  ought  to  embrace  selection  of  a  site,  constructive 
planning,  and  management  of  the  sanatorium. 

Before  entering  more  in  detail  upon  these  features  it  may  be  well 
to  point  out  that  the  results  obtained  in  a  sanatorium  are  in  no  way 
in  proportion  to  the  expense  of  the  institutions.  Excellent  results  can 
be  achieved  in  an  institution  providing  only  the  barest  comforts;  often 
better  ones  than  in  a  most  luxuriously  equipped  sanatorium.  Eesults 
do  not  depend  on  elaborate  equipment,  but  on  the  way  in  which  every- 
thing is  utilized  to  improve  mentally  and  physically  the  condition  of 
the  patient.  From  this  point  of  view  elaborateness  of  equipment,  even 
if  to  some  extent  only  fulfilling  many  of  the  so-called  modern  sanitary 
requirements,  is  often  rather  hampering  than  furthering  the  purposes 
of  a  sanatorium.  The  "  infinite  number  of  discontented  beings  "  who, 
according  to  Cornet  ('07),  return  from  comfortable  sanatoria  to  poor 


SELECTION   OF  SANATORIUM  SITE  643 

domestic  surroundings,  could  be  considerably  lessened  by  adhering 
rigidly  to  the  fundamental  principle  of  extreme  simplicity  in  sana- 
torium construction.  Tliis  answers  the  question  often  asked,  whether 
one  shall  build  cheaply  and  temporarily,  or  expensively  and  perma- 
nently. 

Selection  of  Sanatorium  Site. — Eemoval  of  the  patient  from  the 
usual  indoor  existence  in  a  town  home  to  the  outdoor  life  in  the  countrj^ 
sanatorium  constitutes  in  a  sense  a  change  of  climate  sufficient  for  the 
vast  majority.  The  choice  of  a  climate,  in  the  common  and  wider  sense, 
can  be  guided  by  considerations  discussed  in  another  chapter.  For 
most  patients  it  is  preferable  and  advantageous  that  the  site  be  not 
too  far  removed  from  their  home  and  the  field  of  their  active  ties.  Com- 
parative statistics  of  results  obtained  in  sanatoria  in  mountain  and  low- 
land regions,  for  instance,  diifer  not  sufficiently  to  form  a  material 
basis  for  the  contention,  formerly  very  prevalent,  that  the  sanatorium 
ought  to  be  situated  in  the  mountains  or  some  other  distant  region,  with 
alleged  climatic  advantages.  The  evident  advantage  of  easier  accessi- 
bility, better  and  cheaper  food  supply  from  city  markets  in  sanatoria 
near  home,  is  enhanced  by  the  frequent  observation  that  patients  sent 
to  a  greater  distance  and  to  radically  different  climatic  conditions, 
though  doing  exceedingly  well  while  there,  often  relapse  more  quickly 
and  hopelessly  upon  their  return. 

There  is  hardly  any  town  or  city  in  the  temperate  zone  in  which 
we  live  in  the  neighborhood  of  which  land  cannot  be  procured  with  all 
the  essential  requirements  of  a  sanatorium  site.  These  are,  briefly: 
(1)  A  dry  soil,  covered  with  grass;  (2)  a  cheerful,  pleasant  landscape', 
(3)  absence  of  smoke-  and  noise-producing  enterprises;  and  (4)  acces- 
sibility. Many  other  requirements  are  theoretically  elaborated  in  text- 
books, but  for  practical  purposes  hardly  merit  mention.  Important  here, 
as  in  any  institution  for  the  reception  of  patients,  is,  of  course,  an 
abundant  pure  water  supply  and  facilities  for  proper  sewage  disposal. 
Protection  against  winds,  very  strongly  demanded  by  some  authors  for 
the  site,  sliould  be  noted.  It  is  here  purposely  left  out  as  one  of  the 
essential  requirements  of  a  sanatorium  site  because  protection  against 
wind  can  be  provided  artificially  by  the  planting  of  trees  and  shrubs 
or  shelters  built  of  wood  or  other  material.  The  absence  of  natural 
shelters  alone  should  not  discourage  the  selection  of  a  site  otherwise 
satisfactory.  It  must  also  not  be  forgotten  that  stagnant  air  is  most 
objectionable,  and  often  to  be  found  in  sanatoria  the  site  of  which  was 
selected  with  too  great  regard  for  protection  against  wind.  As  said 
before,  artificial  shelters  can  be  found  against  winds,  especially  in  win- 
ter, when  most  objectionable ;  and,  on  the  other  hand,  refreshing  breezes 
may  be  most  welcome  in  a  hot  summer,  it  being  a  common  experience 


644    THE   SANATORIUM,   ITS   CONSTRUCTION   AND   MANAGEMENT 

in  sanatoria  that  even  excessive  cold  is  well  borne  by  most  patients,  while 
excessive  heat  always  affects  them  badly. 

Dryness  of  ihe  soil  is  of  considerable  importance,  and  merits  careful 
examination  before  deciding  on  a  site.  A  determination  of  the  average 
level  of  the  soil  water  ought  to  be  undertaken  always  if  the  grounds  are 
on  level  land.  This  level  is  usually  low  on  sloping  grounds,  and  for  that 
reason  alone  a  slope  will  merit  preference  even  if  the  quality  of  the 
soil  itself  is  otherwise  imperfect.  Given  a  low  level  of  the  soil  water, 
not  only  on  the  immediate  site  of  the  building  but  also  on  the  sur- 
rounding land  (avoidance  of  marshy  and  swampy  regions),  a  more  or 
less  impervious  clay  soil,  if  no  other  can  be  found,  may  be  chosen, 
because  the  water  will  run  off  and  leave  the  surface  dry.  That  the 
larger  part  of  the  grounds  be  covered  with  grass  is  most  desirable,  be- 
cause thereby  the  formation  of  dust  will  be  prevented  to  a  large  extent. 
It  also  forms  one  factor  in  the  next  important  requirement,  the  cheer- 
fulness of  the  landscape.  This  point  ought  always  to  merit  attention, 
because  there  are  but  few  patients  who  are  not  sooner  or  later  affected 
by  it.  Beautiful  scenery  is  but  rarely  to  be  found  in  the  neighborhood 
of  centers  where  sanatoria  are  needed,  but  the  open  country,  wherever 
it  may  be,  offers  choices  of  sites  which  can  be  considered  from  this  view- 
point, although  with  more  modest  pretensions.  A  sloping,  undulating, 
or  hilly  ground,  also,  in  this  regard,  will  be  more  desirable  than  a  level 
one.  Meadows,  shrubs,  and  trees  add  considerably  to  the  cheerfulness 
of  the  landscape.  Pine-tree  regions  have  for  a  long  time  been  consid- 
ered to  offer  especially  desirable  sites  for  sanatoria.  A  pine  forest  pro- 
vides, indeed,  a  very  good  shelter,  and  the  soil  on  which  the  trees  grow 
usually  fulfills  the  requirement  of  dryness.  Where  natural  beauty  is 
scant,  much  can  be  done  toward  the  artificial  improvement  of  the 
grounds  in  this  respect,  and  a  selection  of  a  site  in  a  bare  country  can 
often  be  made  with  this  in  view.  At  any  rate,  this  point  must  merit 
a  great  deal  more  attention  that  it  has  often  received. 

Absence  of  smol-e  is  the  next  essential.  It  means  pure,  open  air. 
A  few  miles  away  from  the  outskirts  of  any  city  such  air  can  be  found, 
and  if  a  greater  distance  seems  desirable,  it  should  be  more  for  reason 
of  the  inexpensiveness  of  land,  greater  natural  beauty,  than  for  the  fear 
that  occasionally  a  few  clouds  of  city  smoke  will  sweep  the  grounds. 
Coal  smoke  is  certainly  less  harmful  than  fine,  irritating  street  dust; 
but  where  it  is  found,  there  are  usually  also  other  contaminations  of 
the  atmosphere  from  the  same  sources  where  it  originated.  The  imme- 
diate proximity  of  railroads,  of  highroads,  and  of  factories  also  should 
be  avoided  on  account  of  their  smoke,  dust,  and  noise. 

Accessibility  of  the  site  is  another  desideratum  which  merits  atten- 
tion.    Electric  rural  lines  are  being  multiplied   rapidly  nowadays  in 


PLANNING    AND   CONSTRUCTION  645 

the  vicinity  of  cities,  and  form  a  very  satisfactory  means  of  transporta- 
tion to  and  from  the  sanatorium.  Accessibility  is  also  to  be  considered 
because  of  the  necessity  of  a  prompt  supply  of  fresh  provisions  to  the 
institution.  But  the  desideratum  of  accessibility  must  not  outweigh  that 
of  rural  surroundings  and  sufficient  remoteness  from  town  life  and  its 
temptations.  The  sanatorium  and  its  grounds  ought  to  form  a  small 
colony  by  itself,  where  the  inmates  are  busy  getting  well,  an  occupation 
which  ought  to  be  rendered  not  only  useful  to  them,  but  also  interesting. 

This  can  be  much  enhanced  by  appropriate  outdoor  life,  and  espe- 
cially by  provisions  for  useful  occupation.  The  question  of  the  size  of 
sanatorium  grounds  has  therefore  to  be  considered.  Existing  sanatoria 
are  mostly  provided  with  amjsle  grounds  up  to  several  hundred  acres. 
The  size  of  these  institutions  and  the  cost  of  land  will,  of  course,  set 
a  limit.  It  can  only  be  stated  that  a  sanatorium  without  ample  grounds 
under  its  control  cannot  properly  fulfill  its  objects,  as  they  are  nowadays 
understood.  Provision  for  systematic  outdoor  occupation  is  of  essential 
importance  to  the  future  welfare  of  the  patients,  and  it  cannot  be 
obtained  on  cramped  grounds.  The  institution  which  through  rest  treat- 
ment in  the  open-air  galleries  and  occasional  walks  and  overfeeding 
alone  accomplishes  the  famous  ninety  per  cent  of  cures  on  dismissal  is 
doing  work  for  the  "  galleries,"  but  not  for  the  patients,  and  especially 
not  for  their  future.  This  is  well  substantiated  by  the  after-results 
in  patients  treated  in  German  sanatoria  by  this  method  (Klebs,  A.  C, 
'07). 

It  cannot  be  urged  too  much,  not  only  that  the  grounds  be  ample, 
but  also  that  they  be  chosen  with  the  prospective  of  serving  directly 
toward  the  occupation  of  the  patients,  particularly  as  regards  gardening, 
path-making,  etc.,  as  well  as  for  their  diversion  by  certain  games, 
walks,  etc. 

Planning  and  Construction. — After  the  essential  requirements  with 
regard  to  the  nature  and  size  of  the  grounds  have  been  fulfilled,  the 
planning  proper  of  the  sanatorium  buildings  is  comparatively  simple, 
although  technically  more  complex.  Individual  circumstances  will  have 
to  govern  the  procedure  in  each  case.  An  already  existing  ])uilding 
sometimes  will  have  to  be,  and  can  suitably  be,  altered  and  utilized  for 
a  sanatorium,  or  administrative  purposes,  in  the  latter  case  the  patients 
being  accommodated  in  separate  buildings  or  shacks.  Thus  evolved 
what  is  usually  termed  the  cottage  type  of  sanatorium  characteristic  of 
the  sanatoria  in  this  country,  modeled  after  the  Adirondack  Cottage 
Sanatorium.  This  type  does  not  show  any  purjjoscful  ])lanning,  as  is 
sometimes  thought.  It  adapted  itself  merely  to  existing  conditions, 
gradually  increasing  its  capacity  by  additions  of  new  cottages.  The 
type  having  once  become  established,  and  with  satisfactory  curative  re- 


646    THE   SANATORIUM,    ITS   CONSTRUCTION   AND   MANAGEMENT 

suits,  the  advantages  of  it  and  the  one-building  plan  have  frequently 
been  discussed  with  considerable  feeling  by  the  advocates  of  the  two 
types.  It  is  desirable  to  set  aside  prejudices  in  regard  to  this  subject, 
because  au  fond  the  differences  of  the  two  types  are  of  slight  impor- 
tance. 

There  have  to  be  two  distinct  departments  in   every   sanatorium : 

(1)  Administrative,  including  dining  room,  kitchen,  day  rooms,  etc.; 
the  central  heating,  lighting,  and  water  plant,  as  well  as  the  laundry, 
will  in  very  large  institutions  form  a  separate  machinery  department. 

(2)  Sleeping  accommodations  for  the  patients.  The  difference  between 
the  cottage  and  the  one-building  type  of  sanatorium  resolves  itself  into 
the  two  departments  being  structurally  separate  or  connected.  From 
the  plan  wliich  provides  one  separate  administration  building  with  one 
or  more  independent  patients'  cottages  to  the  building  which  under  one 
roof  contains  all  the  departments,  various  transitional  types  can  be  seen 
in  existing  sanatoria.  A  connecting  and  covered  gallery  between  the 
patients'  quarters  and  the  main  building  is  gradually  shortened,  and 
narrow  wings,  with  patients'  rooms,  radiate  from  a  central  building, 
more  or  less  directly  accessible  from  it.  In  a  larger  sanatorium  a 
closer  structural  connection  of  the  departments  facilitates  the  medical 
supervision  and  discipline,  reduces  the  difficulties  of  cleaning  and  serv- 
ice, but  does  not  allow  a  very  desirable  segi'egation  of  patients  into 
groups,  according  to  their  congeniality  and  the  stage  of  the  disease, 
especially  in  buildings  of  more  than  two  stories.  For  this  reason  alone 
higher  buildings,  as  so  often  erected  in  Germany  for  sanatorium  pur- 
poses, do  not  recommend  themselves,  although  it  matters  but  little  how 
many  stories  are  provided  for  the  administration  building. 

From  the  foregoing  is  seen  that  it  is  of  but  little  consequence  what 
type  of  building  plan  is  adopted,  but  in  coristructivc  detail  certain  prime 
requisites  must  be  fulfilled.  For  their  discussion  we  may  suitably  sepa- 
rate the  two  principal  parts  of  the  sanatorium. 

The  Patients'  Quarters. — Abundant  ventilation  is  here,  of  course,  of 
first  importance.  The  requirements  in  this  respect  cannot  be  fixed,  as 
is  customarily  done  in  hospital  buildings,  by  a  certain  cubic  space  per 
bed.  Ventilation  does  not  necessarily  improve  with  the  size  of  an  in- 
closed space,  but  is  dependent  on  the  amount  of  fresh  air  supplied,  which 
obviously  can  be  lacking  in  a  large  room,  while  amply  provided  for 
in  a  small  one.  Mechanical  ventilation  systems,  intended  to  renew  the 
air  by  propulsion  or  traction,  are  of  no  use  in  a  sanatorium;  they  may 
have  some  usefulness  in  the  administrative  part  of  a  very  large  insti- 
tution. In  the  patients'  quarters,  however,  it  is  best  to  rely  entirely 
on  ventilation  through  windows,  or,  better  still,  by  leaving  one  wall 
of  the  bedroom  out  entirely.     This  latter  plan  has  been  employed  in 


PLANNING   AND   CONSTRUCTION 


647 


this  country,  and  its  practicability  was  first  demonstrated  by  Dr.  Millet, 
of  Brockton,  Mass.,  for  small  individual  shacks,  and  by  Dr.  H.  M.  King 
at  the  Loomis  Sanatorium,  Liberty,  N.  Y.,  for  small  wards  (ten  and 
more  patients).  King's  "lean-to"  introduced  one  exceedingly  impor- 
tant feature,  and  one  which  was  bound  to  assure  it  great  popularity — 
i.  e.,  the  addition  to  the  "  open-air  ward  "  of  a  beatable  dressing  room, 
with  bath  and  toilet  appliances.  The  principle  of  the  King  lean-to  has 
been  copied  and  modified  practically  everywhere  in  this  country,  and 
fully  merits  a  still  wider  application.  In  England  of  late  a  similar 
plan  has  been  followed  in  some  sanatoria  (Frimley),  and  a  report  made 
by  the  writer  at  the  International  Tuberculosis  Conference  at  The 
Hague  (Klebs,  A.  C,  '06)  has  served  toward  its  introduction  on  the 
Continent. 

The  ideal  sleeping  unit,  as  at  present  evolved,  can  therefore  be  said 
to  consist  of  a  shelter  offering  protection  against  heat  and  the  weather; 


Fig.  156. — Dr.  Millet's  New  Modified  Shack  for  One  Patient  at  Brockton, 

Mass. 


above  and  below,  and  on  two,  preferably  opposite,  sides  a  beatable  dress- 
ing and  toilet  room  should  be  easily  accessible  from  it.  The  two  opposite 
walls  can  be  left  out  entirely,  but  in  our  climate  it  is  necessary  to  pro- 
vide one  or  both  of  these  spaces  with  some  protecting  fixtures  for  use 
in  inclement  weather.  In  order  to  allow  the  proper  place  of  the  unit 
in  a  coordinate  whole  it  will  usually  be  necessary  to  provide  a  "back- 
wall  "  (against  the  most  exposed  side)  ;  but  in  this  a  window  or  door 
leading  into  a  corridor  will  have  to  be  placed,  providing  the  unit,  when 
open,  with  a  continuous  current  of  air.  The  remaining  fourth  wall 
space  can  then  be  protected,  when  necessary,  by  an  awning,  or  often 


648   THE   SANATORIUM,    ITS   COiNSTRUCTION   AND   MANAGEMENT 

the  overhanging  roof  affords  all  the  protection  required.     The  impor- 
tance of  free  cross- ventilation  cannot  be  sufficiently  insisted  on;  often 


Fig.  157. — Open-air  Gallery  Joinixg  Two  Buildings. 
Gaylord  Farm  Sanatorium,  Wallingford,  Conn. 

in  cubicles,  with  one  wall  left  out,  the  air  is  found  stagnant  except  when 
it  happens  that  the  wind  blows  into  it.  Not  too  much  reliance,  there- 
fore, must  be  placed  on  ventilation  by  diffusion  only;  even  when  the 


Fig.   158. — Dr.   King's  Original  "Lean-to"  for  Eight  Patients  at  Loomis 
Sanatorium,  Liberty,  Sullivan  County,  N.  Y. 

opening  to  the  outer  air  is  quite  large,  it  must  be  supplemented  by 
cross-current  ventilation. 


Fig.   loy. — Two  "Lean-tos"  of  the  Loomis  SANATORiUiM,  Liberty,  Sullivan 

County,  N.  Y. 


Fig.  160. — Dr.  King's  Modified  and  Enlarged  "Lean-to"  (Anne  M.  Loomis 
Memorial)  for  Sixteen  Patients.  Loomis  Sanatorium,  Liberty,  Sullivan 
County,  N.  Y. 

43  649 


650   THE   SANATORIUM,   ITS   CONSTRUCTION  AND  MANAGEMENT 

The  development  of  the  constructive  evolution  of  the  patients'  quar- 
ters in  America  contains  so  many  suggestive  data  that  it  may  be  well 
to  discuss  it  here  by  means  of  suitable  pictures. 

It  can  be  safely  stated  that  the  type  evolved  in  this  country  will  be 
adopted  more  and  more,  and  everywhere,  with  modifications  demanded 
by  local  conditions.  Figure  156  shows  Dr.  Millet's  latest  modification  of 
his  shack  for  one  patient.  Here  we  see  all  the  basic  principles  which 
have  guided  the  construction  of  sleeping  pavilions:  an  open  part,  in- 
tended for  the  patient's  accommodation  at  night,  and  one  inclosed  part 
for  his  toilet.  This  general  scheme  is  applied  for  use  by  more  than  one 
patient  in  several  sanatoria  by  a  utilization  of  porches  and  balconies 
for  the  housing  of  patients.    This  may  serve  its  purpose  in  many  cases, 


Fig.  161. — Interior  of  Sitting-room,  Showing  Locker,  Toilet,  and  Bath- 
rooms IN  THE  Rear  of  a  Sixteen-Bed  "Lean-to."  Loomis  Sanatorium,  Lib- 
erty, Sullivan  County,  N.  Y. 


but  in  general  is  not  to  be  recommended  because  of  its  obstruction  of 
air  and  light  for  the  adjoining  rooms  in  the  main  building. 

Sometimes  two  buildings  are  joined  by  a  gallery  open  to  the  weather 
on  one  side,  which  gives  a  very  well  protected  and  perfectly  sufficient 
accommodation  for  patients,  who  for  their  toilet  can  retire  into  one  of 


PLANNING   AND   CONSTRUCTION  651 

the  houses.  Such  an  arrangement  has  been  proposed  in  the  constructive 
planning  of  some  sanatoria,  but  more  often  has  it  been  used  where  old 
buildings  have  been  utilized  for  the  accommodation  of  patients,  as,  for 
instance,  at  the  Gaylord  Farm  Sanatorium,  in  Wallingford,  Conn.  (Fig. 
157). 

The  first  purposeful  application  of  this  principle,  however,  we  see 
carried  out,  as  has  already  been  mentioned,  in  Dr.  King's  "  lean-to," 


Fig.  162. — One  of  Two  Sleeping  Galleries  of  Dr.  King's  Sixteen-Bed 

"Lean-to." 

of  which  several  photographs  are  here  given.  Figure  158  shows  the 
elevation  of  King's  original  "  lean-to."  It  is  a  very  primitive  structure, 
but  has  served  its  purpose  exceedingly  well  throughout  the  year — sum- 
mer and  winter — without  discomfort  to  the  patients.. 

It  may  be  said  here  that,  as  a  general  rule,  patients  very  readily 
become  accustomed  to  sleeping  in  these  structures,  and  that  it  often 
becomes  difficult  to  induce  them  to  return  to  other  more  solidly  built 
apartments.    » 

Dr.  King  and  others  have  elaborated  considerably  this  original  "  lean- 
to,"  so  that  greater  comfort  has  been  insured  at  no  considerable  increase 
in  expenditure. 


652   THE  SANATORIUM,   ITS   CONSTRUCTION   AND   MANAGEMENT 

Figures  159  and  160  show  such  modifications  as  are  at  present  in 
use  at  the  Loomis  Sanatorium.  Tliey  only  differ  from  tlie  original 
"  lean-to  "  in  giving  more  space  throughout,  in  the  sleeping  gallery  as 


Fig.  163. — Open-air  Pavilion  Connected  with  Main  Building.  Infirmary 
rooms  upstairs.  Maine  State  Sanatorium.  Designed  by  Dr.  Estes  Nichols, 
Hebron,  Me. 

well  as  in  the  locker  and  toilet  rooms.  The  jihotographs  give  a  better 
description  of  tlicse  constructive  details  than  can  be  done  in  words.  A 
sitting  room  is  provided  in  these  more  recent  modifications,  occupying 
the  central  part  of  tlie  structure  (Fig.  ICl),  and  from  which  immediate 


Fig.  164. — Dr.   Holden's  Open-air   Pavilion,  Agnes  Memorial  Sanatorium, 

Denver,  Colo. 

access  can  be  had  to  the  locker  and  toilet  rooms.  On  the  sleeping  gal- 
lery (Fig.  162)  sufficient  space  is  to  be  found  in  front  of  the  beds  for 
the  patients  to  circulate  and  to  rest  on  their  steamer  chairs.     It  will 


PLANNING   AND   CONSTRUCTION 


653 


be  noted  that   in  these  structures  the  protection  from  the  weather  is 
obtained  only  by  an  overhanging  roof  and  by  an  awning. 

Otlier  modifications  of  this  "  lean-to "  scheme  show  attempts  at  a 
more  solid  protection  against  the  weather.     This  we  see  particularly  in 

I 


\|3Ttl 


the  open-air  pavilions  at  tlie  jMaine  State  Sanatorium,  at  Hebron.  Me. 
(Fig.  163),  and  at  the  Agnes  Memorial  Sanatorium,  in  Denver  (Figs. 
l()-t  and  165).  In  the  latter  the  protection  is  obtained  by  large  French 
windows,  which  are  open  to  the  outside,  obstructing  in  no  way  the 


654    THE   SANATORIUM,    ITS   CONSTRUCTION   AND   MANAGEMENT 

passage  of  air.  In  the  former  large  doors  are  provided,  an  arrangement 
similar  to  that  at  the  Frimley  Sanatoria. 

Figure  163  shows,  also,  how  the  open-air  pavilion  can  be  connected 
directly  with  the  main  building.  The  pavilion  contains  no  corridor, 
and  access  to  the  main  building  is  to  be  had  directly  through  one  door, 
the  pavilion  not  being  divided  up. 

At  the  Agnes  Memorial  Sanatorium  partitions  are  used  to  separate 
the  patients,  an  arrangement  which  may  offer  considerable  advantage  in 
some  institutions  where  more  advanced  cases  have  to  be  admitted.     In 


Fig.  166. — Boston  Consumptives'  Hospital  at  ]\Iattapan. 
Front  elevation  of  Cottage  Ward. 


general,  it  does  not  seem  to  be  an  advisable  practice,  at  least  not  for 
patients  in  the  earlier  stages,  who  ought  to  constitute  the  major  portion 
of  the  inmates  of  the  sanatorium. 


LH  GLND 
A  ASSEMBLY  ROOM 

C    LOCKER- ROOM 
P    TOILtT 
E    NUtSE'5   tOOM 
f    IMECCtMCY  E.OOM 
G    PI  A'ZZ  A 


pddflfltldDdDt]] 


Fig.  167. — Boston  Consumptives'  Hospital  at  Mattapan. 
Floor  plan  of  Cottage  Ward. 

It  is  of  interest  to  note  that  the  "  lean-to  "  scheme  has  of  late  been 
adopted  also  for  hospitals  admitting  advanced  cases.     Figures  166  and 


PLANNING  AND  CONSTRUCTION 


655 


167  show  the  elevation  and  the  floor  plan  of  a  cottage  ward  at  the  Boston 
Consumptives'  Hospital  at  Mattapan.  In  this  admirahle  plan  an  emer- 
gency room  and  a  nurses'  room  have  been  added  very  appropriately,  but 


Fig.  168. — Boston  Consumptives'  Hospital  at  Mattapan.    Day  camp. 

on  the  whole  the  deviation  from  the  plan  of  the  original  "'  lean-to  "  of 
King  is  but  very  slight.     We  also  find  a  similar  principle  carried  out 


LEGE/ND        j 

A 

J  TOM   tOOM 

ft 

t;.rrcME/N- 

C 

PtlVATI  DfNINC  iM 

D 

DININC  R.OOM 

E 

MENS'  E,OOM 

F 

WOMINi  ROOM 

C 

TOILET  R.OOM 

H 

IAVATOB.Y 

1 

THEOAT  EMM.E.M 

J 

LABORATOE.Y 

K 

OfriCES 

L 

CotB-IDOl? 

M 

PAJJACE. 

H 

LINEN  R.OOM 

O 

COAL    BOX 

P 

PIAZZA 

Fig.  169. — Boston  Consumptives'  Hospital  at  Matt.vpan. 
Floor  plan  of  day  camp. 


in  the  day-camp  building  of  the  same  hospital  (Figs.  168  and  169), 
although  the  inclosed  spaces  here  are  used  for  different  purposes  than  in 
the  other  arrangement,  a  large  dining  room  occupying  the  greatest  space. 


656   THE  SANATORIUM,   ITS   CONSTRUCTION   AND   MANAGEMENT 


Mr.  Edwin  T.  Hall,  the  successful  architect  of  the  Frimley  Sana- 
torium, considers  the  "  two  essential  details  in  the  design  of  a  sanato- 
rium: First,  that  all  windows  or  other  openings  shall  be  carried  up  to 
the  ceilings,  so  that  all  parts  of  the  rooms  and  corridors  may  be  scoured 
with  fresh  air;  second,  the  sanitary  apparatus  should  be  external  to 
the  building." 

It  is  seen  from  the  above  descriptions  that  the  "  lean-to  "  scheme 
amply  fulfills  these  two  requirements.  In  his  plans,  Hall  favors  single- 
bed  wards,  but  considers 
two-  and  three-bed  wards 
as  useful,  deviating  there- 
by from  the  American 
practice,  where  as  many 
as  sixteen  and  more  are 
comfortably  acconnnodat- 
ed  in  one  open-air  pavil- 
ion. The  question  as  to 
whether  single  or  multi- 
ple wards  shall  be  con- 
structed depends  wholly 
on  the  class  of  patients 
to  be  accommodated  in 
the  sanatorium;  but,  on 
the  whole,  it  has  been 
found  that  tlie  larger 
ward  offers  in  itself  fea- 
tures conducive  to  better 
discipline  and  a  better 
comradeship  among  the 
patients,  very  lielpful  in 
a  regime  which,  of  ne- 
cessity, requires  a  long 
period.  The  "  lean-to  " 
scheme  also  does  away  en- 
tirely with  porches  ad- 
FiG.  170.— Main  Building  (Floor  Plan  of  First  -joinino'  other  buildings, 
Story)  for   Sanatorium   for    100  Patients.  ,-,        7-  ■       7    77         1  ■  1 

„      ,         ,.  ^  .,    X-        f    J    •  •  X    X-        £c  or    the    Lieqelialle    which 

lo  show  distribution  01  administrative  othces,  "^ 

laundry,    etc.      (J.  Gamble  Rogers,  Architect,      forms     the     characteristic 
N.  Y.,  from  suggestions  of  Dr.  A.  C.  Klebs.)          feature  of  the   Continen- 
tal European  sanatorium. 
The  disappearance  of  the  LiegeJialle  can  only  be  welcomed,  since  it  has 
been  more  and  more  realized  that  the  treatment  by  absolute  rest  during 
the  day,  for  many  hours  at  a  time,  is  not  favorable  for  permanent  recov- 


Tik-5T  5TDie-r  TLAri 


THE   ADMINISTRATION    BUILDING 


657 


er}^  and  frequently  creates  dissatisfaction,  unhappiness,  and  idle  habits 
among  the  patients.  The  graduated  exercises  and  labor  so  successfully 
carried  out  by  Paterson  at  Frimley,  which  have  been  described  in  the 
foregoing  chapter,  invite 
a  more  general  adoption 
in  sanatorium  practice, 
and  will  further  and  fur- 
ther remove  the  necessity 
of  special  structures  for 
the  open-air  rest  cure. 

The  material  to  be 
used  for  the  building  of 
the  patients'  quarters  will 
be  discussed  later,  to- 
gether with  the  cost  of 
sanatoria  in  general. 

The  Administration. 
Building. — Provision  for 
the  administrative  offices, 
for  the  dining  room, 
kitchen,  and  laundr}^  and 
for  laboratories,  can  be 
made  in  one  central 
building  for  institutions 
of  considerable  size.  It 
will  sometimes  be  desira- 
ble to  have  separate  small 
houses  for  physicians' 
quarters,  for  the  power 
plant,  and  for  the  farm, 
but  that  will  depend  en- 
tirely on  the  amount  of 
money  at  disposal,  and  on 
the  purposes  of  the  sana- 
torium. It  may  be  said, 
in  general,  that  an  elaborateness  of  planning  is  unde^^irable  in  the  major- 
ity of  institutions.  There  will  have  to  be  institutions  where  special 
research  is  carried  on  and  everything  done  on  a  larger  scale — as,  for 
instance,  in  the  superb  King's  Sanatorium  at  Midhurst,  England. 
The  writer  has  proposed,  several  years  ago,  a  sanatorium  consisting 
of  an  administration  building,  together  with  accommodations  for  the 
patients  in  "lean-tos."  The  adjoining  plans  (Figs.  170  to  172) 
may    prove    suggestive    to    anyone    contemplating    the    erection    of    a 


SeicoND  FLooK  Pl^N 

Fig.  171. — Main  Building  (Floor  Plan  of  Sec- 
ond Story)  for  SanatoriuxM  for  100  P.a.- 
tients.  To  show  distribution  of  dining  room, 
pantry,  kitchen,  etc.  Above  are  rooms  for 
physicians,  nurses,  and  help.  (J.  Gamble  Rogers, 
Architect,  from  suggestions  of  Dr.  A.  C.  Klebs.) 


658   THE   SANATORIUM,   ITS  CONSTRUCTION  AND   MANAGEMENT 


larger   sanatorium.      It   is   not   necessary 
plans;    they    are    self-explanatory.       It 


CBOUMD  PLAM  LEAMTO                         Acte  ..A.  .:.• 

Fig.    172.~-H.    M.  King's     Type    of    16-Bed 

"  Lean-to  "     in  Connection    with    Main 
Building. 


to  describe  in  detail  these 
may,  however,  be  well  to 
state  that  the  space  in 
the  second  floor  assigned 
to  the  dining  room  in  the 
front  part  of  the  struc- 
ture seemed  to  be  more 
desirable  than  any  other, 
because  of  its  exposure 
to  both  light  and  air 
from  all  sides.  Accom- 
modations for  help  arc 
to  be  found  in  the 
third  story  above  the 
kitchen. 
A  very  similar  scheme  has  been  adopted  most  recently  in  the  plan- 
ning of  the  Maryland  Tuberculosis  Sanatorium,  at  Sabillasville,  Md. 
(Fig.  173),  an  institution  intended  for  one  hundred  patients.  It  will 
be  advisable  in  the  planning  of  an  administration  building  to  have  it 
60  arranged  that  it  can  be  easily  added  to,  especially  in  the  spaces  as- 
signed to  the  dining  room  and  the  kitchen  departments.  When  the 
patients  are  accommodated  at  night  in  "  lean-tos,"  these  can  be  added 
to  more  or  less  indefinitely,  while  the  administration  building,  if  not 
planned  with  a  view  to  a  possible  growth  of  the  institution,  is  more  or 
less  an  unchangeable  feature  of  the  sanatorium. 

General  Planning  of  the  Sanatorium  Building. — If  the  patients  are 
accommodated  in  shacks  or  "  lean-tos,"  these  latter  are  to  be  placed  as 
near  as  possible  to  the  administration  building  without  suffering  thereby 
from  too  great  an  obstruction  of  light  and  air.  In  some  of  the  existing 
sanatoria,  some  of  the  shacks  or  "  lean-tos  "  are  entirely  too  far  removed 
from  the  central  building,  necessitating  considerable  walking  for  the 
patients  to  reach  the  dining  room  at  meal  times.  It  seems  to  the  writer 
that  the  arrangement  as  provided  at  the  Maryland  sanatorium  is  one 
of  the  best.     Figure  174  shows  this  clearly. 

Building  Material  and  Cost. — On  the  selection  of  the  building  mate- 
rial, the  cost  of  the  sanatorium  will  very  largely  depend.  This  subject 
has  been  discussed  very  extensively  at  the  various  national  and  inter- 
national tuberculosis  meetings  without  ever  having  brought  forth  a 
practical  solution  of  the  question.  The  difficulty  of  fixing  an  average 
cost  per  bed  for  a  sanatorium  meets  with  considerable  difficulty,  because 
the  material  for  building,  the  land,  and  labor  will  vary  in  different 
districts.  One  thing,  however,  can  be  said  with  certainty :  that  the  esti- 
mates of  cost  for  popular  sanatoria  which  have  been,  given  by  some 


BUILDING   MATERIAL  AND   COST 


659 


authors  are  entirely  too  high.  The  minimum  figures  exceed,  in  some 
cases,  $1,000  per  bed  considerably.  x\t  such  a  rate  it  would  be  impos- 
sible to  multiply  sanatoria  to  a  desirable  degree.     It  is  very  essential 


Fig.  173. — Floor  Plan  of  First  Floor  of  Administration  and  Infir.mary 
Buildings  of  Maryland  Tuberculosis  Sanatorium  at  Sabillasville, 
Md.     (Wyatt  &  Nolting,  Baltimore,  architects.) 


660    THE   SANATORIUM,    ITS   CONSTRUCTIOxN   AND   MANAGEMENT 

that  it  should  be  understood  that  at  smaller  figures  perfectly  comfort- 
able and  efficient  buildings  can  be  constructed  which  will  fulfill  all  the 
requirements;  and  it  must  be  said,  in  addition,  that  the  efficiency  of 
a  sanatorium  rather  decreases  in  proportion  with  the  increase  of  comfort 
and  elaborateness,  and  that  therefore  any  individual  or  any  community 
contemplating  the  erection  of  a  sanatorium  should  not  be  deterred  from 


■SHA  C  K 


^HACK 


^HACK 
I*— '^— 


^HACK 


SHACK 
I"—"— 


SHACK 


rgfc^ 


^HACK 
— " 1| 


5HACK 
II       II ' 


5HACK 
— " 'I 


.SHACK 
II       j~~ 


Fig.  174. — Bird's-eye  View  of  Maryland  Tuberculosis  Sanatorium,  Sabillas- 
viLLE,  Md.     (Wyatt  &  Nolting,  Baltimore,  architects.) 


SO  doing  by  such  estimates  based  on  minimum  figures  of  $1,000  per 
bed.  As  said  above,  the  whole  question  rests  to  a  great  extent  on  the 
selection  of  building  material,  wood  being  the  cheapest  and  stone  the 
most  expensive.  In  this  country,  wood  has  been  very  largely  used.  The 
canvas  tent,  which  is  still  cheaper,  has  practically  been  given  up  because 
of  its  flimsy  nature  and  other  disadvantages.    When  one  sees  the  wooden 


MANAGEMENT  AND  SANATORIUM   REGIME  661 

chalets  in  the  storm-swept  valleys  of  Switzerland,  which  have  stood  the 
inroads  of  time  and  weather  for  very  considerable  periods,  it  does  not 
seem  correct  to  speak  of  wooden  structures  as  "  temporary  "  buildings. 
It  is  of  importance  to  keep  this  in  mind,  because  the  use  of  wood  for 
sanatorium  construction  has  been  very  often  discouraged,  and  even  ridi- 
culed, because  of  not  offering  elements  of  permanency.  Its  inflammable 
nature,  of  course,  is  of  disadvantage,  but  very  little  so  for  the  smaller 
buildings  called  for  in  the  "  lean-to  "  type.  For  a  large  central  admin- 
istration building,  its  use  may  not  recommend  itself  throughout,  but 
it  7nay  be  stated  that  there  is  no  objection  to  its  extensive  use  in  the 
planning  of  a  modern  sanatorium.  It  is  possible  that  cheaper  substitutes 
than  wood  may  soon  be  found.  Some  efforts  in  this  direction  have  been 
made;  for  instajnce,  in  the  Doecher  BarracTcs,  which  are  extensively  used 
in  Germany  in  a  similar  manner  as  tents  are  used  in  this  country. 
Chemically  treated  cardboard  is  the  chief  material  used  in  their  con- 
struction. 

Mr.  Edwin  T.  Hall  has  of  late  recommended  in  his  scheme  of  a 
standardized  expanding  sanatorium  dry  slabs  of  standard  size,  which 
are  universal  in  application  for  the  building  unit.  It  would  be  inter- 
esting and  valuable  to  have  further  details  on  this  building  material. 
Hall  says: 

"  A  sanatorium  on  these  lines,  complete,  with  all  essential  adminis- 
trative buildings,  to  suit  any  required  number  of  beds,  with  drains  fitted 
to  kitchen  and  laundry,  and  water  storage,  can  be  erected  on  a  suitable 
and  reasonably  accessible  site  at  a  cost  of  about  £85  ($425)  to  £105 
($525)   per  bed,  depending  upon  its  size." 

This  scheme,  it  would  seem,  merits  distinct  attention  as  one  coming 
from  so  experienced  an  architect  as  the  builder  of  the  Frimley  Sana- 
torium. The  estimates  for  sanatoria  in  this  country,  with  wood  entering 
primarily  into  its  construction,  does  not  exceed  these  figures  given  by 
JMr.  Hall.  They  would  help  to  fulfill  the  desiderata  recently  expressed 
by  Heron :  "  All  jjoor  consumptives  should  be  sent  into  sanatoria  for 
tlieir  own  sakes,  and  for  the  sake  of  the  health  of  the  community.  This 
could  not  be  done  if  sanatoria  were  built  costing  $1,000  to  $4,000  per 
bed.  A  sanatorium  well  equipped  for  the  service  of  the  poor  should 
not  cost  more  than  $400  per  bed." 

Management  and  Sanatorium  Regime. — It  is  not  necessary  to  enter 
here  in  detail  into  the  administrative  features  of  the  sanatorium,  nor  is 
it  necessary  to  outline  the  hygienic  and  dietetic  regime  which  is  fol- 
lowed in  several  institutions.  The  former  will  have  to  vary  according 
to  circumstances,  and  the  latter  is  carried  out  on  the  principles  already 
discussed  in  the  foregoing  chapter.  It  is  desirable,  however,  to  point 
out  again  that  in  the  future  it  will  become  more  and  more  necessary 


662    THE   SANATORIUM,   ITS   CONSTRUCTION   AND   MANAGEMENT 

to  utilize  the  available  working  capacity  of  the  patients  toward  the 
maintenance  of  the  institution;  and  it  will  be  of  great  advantage  if  it 
becomes  more  and  more  understood  that  in  such  a  plan  not  the  interests 
of  the  institution  itself  are  kept  in  mind  as  much  as  the  benefit  to  the 
patients  themselves.  Many  of  those  being  in  charge  of  sanatoria  have 
complained  about  the  great  difficulty  of  inducing  patients  to  do  any- 
thing else  during  their  sojourn  in  the  sanatorium  than  to  take  care  of 
themselves;  but,  on  the  other  hand,  we  have  many  reports  from  sana- 
toria where  a  purposeful,  energetic  scheme  of  providing  useful  work 
for  the  patients  has  succeeded.  To  restore  the  patient's  embonpoint 
and  to  destroy  his  working  energy  and  capacity  has  been  for  too  long 
the  result  of  a  sanatorium  regime,  and  it  is  high  time  that  a  greater 
amount  of  common  sense  be  applied  to  these  highly  important  questions. 
The  purpose  of  the  sanatorium  regime  must  be  to  maintain  or  to  im- 
prove the  patient's  working  capacity,  and  that  cannot  be  accomplished 
by  a  long-continued  idleness.  If  such  idleness  is  the  only  means  by 
which  a  patient  can  hold  in  check  his  symptoms  of  disease,  then  the 
place  for  such  a  patient  is  not  in  a  sanatorium,  but  in  a  hospital,  from 
whence,  perhaps,  at  some  future  time,  if  his  condition  continues  to 
improve,  he  may  be  returned  to  the  sanatorium.  Such  considerations 
will  fix  more  definitely  the  range  of  usefulness  of  the  sanatorium,  and 
will,  perhaps,  enhance  the  position  of  the  hospital  to  receive  all  kinds 
of  patients  suffering  from  tuberculosis,  and  admitted  particularly  from 
the  large  centers  of  population.  The  plans  of  institutional  provision  for 
sufferers  from  tuberculosis  have  not  yet  reached  the  last  stage  of  evolu- 
tion; but  it  is  very  likely  that  it  will  be  found  in  a  successful  cooperation 
of  a  receiving  hospital  and  multiple  sanatoria. 


CHAPTER   IV 
CLIMATIC    TREATMENT 

THE   PHYSIOLOGY  OF  CLIMATE 
By  HExNfRY  SEWALL 

RELATION    OF    CLIMATE    TO    PHYSICAL    AND    PSYCHICAL 

CONDITION 

Medical  climatology  is  based  on  the  theory  that  the  physiologic 
activities  of  the  human  mechanism  are  specifically  stimulated  or  de- 
pressed, made  easier  or  more  difficult,  according  to  the  nature  of  the 
climatic  environment.  It  would  seem  to  be  self-evident  that  every 
vital  function  must  react  in  a  definite  way  to  definite  changes  in  the 
physical  factors  of  climate. 

Unfortunately  for  the  solution  of  the  problem,  the  scientific  observer 
cannot  often  test  the  effect  of  specific  physical  conditions  or  of  isolated 
functions,  but  must  deduce  conclusions  from  the  resultants  of  many 
interacting  variables. 

In  the  living  body  the  coordination  of  various  activities  is  relegated 
to  a  special  mechanism — the  nervous  system — through  whose  interfer- 
ence the  response  of  any  tissue  to  a  stimulus  is  modified  by  the  asso- 
ciated effects  on  other  tissues.  For  example,  when  a  living  heart,  iso- 
lated from  the  body,  is  perfused  with  a  nutrient  solution,  its  rate  of 
beat  will  remain  unchanged  through  a  wide  range  of  resistance  to 
outflow  from  it.  The  heart  wall  simply  contract  more  or  less  forcibly, 
according  to  the  work  imposed  on  it.  But  in  the  normal  body  an 
increase  of  resistance  to  outflow^  from  the  heart  at  once  excites  a  regu- 
lator apparatus  through  which  not  only  is  its  rhythm  slowed,  but  a 
profound  influence  is  impressed  on  the  vasomotor  mechanism,  not  to 
speak  of  more  remote  effects. 

Many  similar  illustrations  might  be  furnished  of  the  important  fact 
that  the  intrinsic  action  of  a  stimulus  on  a  certain  organ  is  apt  to  be 
completely  masked  by  the  associated  reactions  of  other  mechanisms. 
Nevertheless,  nothing  is  more  certain  than  that  such  a  hypothetical 
increase  of  resistance  to  outflow  from  the  heart  would  ])roduce  in  it  a 

663 


664  THE   PHYSIOLOGY   OF  CLIMATE 

vital  reaction  of  far-reacliing  import,  the  simplest  manifestation  of 
which  would  he  found  in  hyjiertrophy  of  the  organ. 

The  illustration  will  serve  its  purpose  if  it  makes  clear  the  position 
that  the  reaction  of  the  animal  organism  to  a  stimulus,  of  wliich  a 
climatic  change  may  be  regarded  as  a  very  complex  example,  is  at 
least  twofold  in  its  nature.  First,  there  is  a  response  through  the  modi- 
fication in  coordination  of  the  vital  activities.  This  is  an  attribute  of 
the  nervous  system,  and  its  effect  is  immediate.  Second,  there  proceeds 
a  change  in  every  tissue,  the  nature  and  extent  of  which  depends  on 
the  reaction  of  that  tissue  to  the  variation  of  physical  and  cheniical 
forces  acting  on  it.  We  are  here  contemplating  the  physiology  of  organic 
nutrition  whose  elaboration  is  gradual  and  its  effects  I'emote. 

We  have  thus  far  considered  only  the  relations  of  climatic  influences 
to  that  part  of  the  nervous  system  which  is  concerned  with  the  vegetative 
functions.  But,  as  it  is  conceded  that  there  is  a  physiology  of  climate, 
still  more  is  it  apparent  that  the  effects  on  the  human  organism  of 
place  and  change  of  place  depend  primarily  on  reactions  of  the  psycliical 
functions,  and  that  therefore  a  consideration  of  psychology  is  indispen- 
sable to  any  broad  conception  of  medical  climatology. 

The  difference  in  feeling,  ranging  from  depressing  lassitude  to  ex- 
hilarant  energy,  or  from  gloom  to  joy,  which  may  be  based  on  condi- 
tions of  weather  and  climate,  is  familiar  to  everyone.  Not  so  evident 
is  the  reaction  of  the  psychic  state  on  the  vegetative  processes  of  me- 
tabolism. That  such  relations  exist,  though  the  science  which  should 
classify  them  may  have  no  name,  cannot  be  gainsaid.  Brackett,  Stone, 
and  Low  ('04)  give  reason  for  believing  that  painfvd  mental  emotions, 
such  as  fright,  can  produce  profound  disturbances  of  metabolism  de- 
noted by  acetonuria,  and  marked  by  vomiting,  collapse,  or  even  death. 
The  inevitable  influence  of  the  psychic  state  on  physiologic  function  has 
become  the  most  prominent  doctrine  of  modern  therapeutics,  and  so  de- 
monstral)le  are  the  interaction  of  mind  and  living  matter,  that  a  powerful 
sect,  an  unwilling  liandmaid  of  science,  has  been  founded  on  its  facts. 

In  a  preceding  paragraph  there  was  suggested  an  antagonism  be- 
tween the  vital  effects  immediately  attendant  on  a  change  of  climate, 
and  those,  often  totally  different  in  character,  which  may  develop  dur- 
ing permanent  residence.  In  short,  a  change  of  scene,  irrespective  of 
the  character  of  the  environment,  has  often,  temporarily,  a  mysteri- 
ous influence  for  good  on  the  living  organism.  As  pointed  out  above, 
the  first  vital  reactions  to  new  climatic  conditions  involve  especially  the 
nervous  system,  the  final  effects  are  dependent  on  the  modified  me- 
tabolism of  the  individual  organs,  and  this  may  or  may  not  be  con- 
ducive to  the  efficiency  of  the  body  as  a  whole. 

The  necessity  of  a  change  in  the  intensity  of  physical  stimuli  to 


RELATION   OF   CLIMATE   TO   PHYSICAL   CONDITION  665 

properly  develop  physiologic  functions  seems  to  be  an  inherent  demand 
of  living  matter.  I)u  Bois-Reymond  was  the  first  to  demonstrate  that 
it  is  the  rate  of  change  in  intensity  of  an  artificial  stimulus  which 
determines  the  excitement  of  nerve  tissue.  It  is  an  elementary  fact  of 
physiology  that  fatigue  progressively  blunts  the  sensory  impression 
aroused  by  a  steady  irritation.  Erlanger  and  Hooker  ('04)  have  gone 
far  to  show  that  the  variation  of  arterial  blood-pressure  incident  to  the 
normal  cardiac  cycle,  the  pulse-pressure,  provides  a  succession  of  shocks 
which  is  indispensable  to  the  normal  activity  of  the  tissues. 

Huggard  ('06)  records  as  an  apparent  exception  to  the  laws  of 
medical  climatology,  that  "  the  newcomer  from  a  temperate  climate  for 
a  time  tolerates  the  extreme  cold  of  the  arctic  regions  and  the  extreme 
heat  of  the  tropics  better  than  do  the  inhabitants  or  natives  themselves." 
After  a  time,  however,  the  immigrant  becomes  abnormally  susceptible  to 
the  chill  of  cold  or  a  victim  to  the  listlessness  induced  by  excessive  heat. 
So  far  from  being  an  exception,  in  the  light  of  the  foregoing  discussion,  it 
seems  to  the  writer  that  such  a  result  is  just  what  should  be  expected. 

A  frequent  experience  of  physicians  who  deal  with  cases  of  pulmo- 
nary tuberculosis  in  health  resorts  apparently  belongs  to  the  same  cate- 
gory. An  invalid  who  leaves  a  favorable  environment  and  returns  to 
former  scenes  and  habits  may,  for  a  time,  lay  on  weight  and  acquire  a 
feeling  of  well-being  which  seem  to  betoken  a  new  lease  on  life.  But 
too  often  the  forces  of  disease  advance  under  the  mask  of  improvement, 
until  vital  resistance  is  hopelessly  undermined.  This  may  also  be  a 
basis,  in  part,  of  the  popular  impression  that  people  may  "  wear  out  " 
a  climate,  at  least  in  so  far  as  an  occasional  change  of  residence  is 
essential  to  maintain  the  normal  health.  Dwellers  in  stimulating  high 
climates  seem  especially  to  feel  the  necessity  for  a  descent,  now  and  then, 

to  lower  levels. 

< 

Every  change  of  environment  leads  to  physiologic  reactions  which 
manifest  themselves  primarily  as  efforts  of  nervous  coordination.  The 
element  of  time  is  an  important  factor  in  the  accomplishment  of  this 
vital  adjustment.  The  process  of  physiologic  adaptation  to  new  physical 
conditions  is  commonly  known  as  acclimatization.  The  perfection  of 
acclimatization  is  measured  by  the  machine  efficiency  attained  by  the 
living  body;  the  resistance  to  its  accomplishment  is  measured  by  the 
climatic  physical  differences  to  be  overcome  and  by  the  individual  and 
racial  vitality  of  the  reacting  organism.  The  final  outcome,  whether 
the  living  mechanism  increases  in  power  or  gradually  succumbs  to  ob- 
stacles which  it  cannot  surmount,  is  a  problem  of  nutrition  which 
involves  as  variables  the  vital  forces  of  all  living  cells. 

The  clinician  who  deals  with  impoverished  constitutions  has  learned 
that  physical  and  mental  rest  on  the  part  of  his  patient  is  indispensable 


666  THE  PHYSIOLOGY  OF   CLIMATE 

in  order  that  the  physiologic  powers  may  attain  their  new  coordinations 
unimpeded.  The  physiologist  has  demonstrated  that  training,  or  gradu- 
ated exercise  of  functions  in  the  direction  demanded,  is  of  paramount 
necessity  to  machine  efficiency  under  radically  changed  climatic  con- 
ditions. 

CLASSIFICATION   OF   CLIMATES 

It  is  impossihle  to  make  a  classification  of  climates  in  which  the 
groups  shall  he  qualitatively  sharply  distinguished  from  one  another. 
Many  schemes  of  division  have  been  proposed,  according  to  the  point 
of  view  of  the  observer.  It  is  curious  to  note  that  the  most  elaborate 
systems  are  but  natural  extensions  of  Aristotle's  original  conception, 
that  the  properties  of  matter  are  all  derived  from  four  elements — earth, 
air,  fire,  and  water.  The  principal  physical  factors  that  determine 
climate  are  temperature,  light,  humidity,  air  movement,  air  density, 
water,  and  soil.  Actual  climates  depend  on  various  combinations  of 
these  factors. 

Medical  climatologists  have  attempted  to  make  their  geographical 
survey  along  lines  determined  by  the  physiologic  reactions  of  the  or- 
ganism.    Thus  Weber  ('04)  makes  a  division  into — 

I.  Sea  and  Coast  Climates. 
II.  Inland  Climates. 

A.  Of  High  Altitudes. 

B.  Of  Moderate  and  Low  Altitudes. 

Another  common  geographic  division  is  into  zones  parallel  to  the 
equator.  Thus:  (1)  Tropical,  (2)  subtropical,  (3)  temperate,  (4)  cold, 
(5)  arctic.  These  schemata,  when  further  elaborated,  put  in  apposi- 
tion geographic  and  physiologic  data  in  a  form  very  convenient  to  the 
medical  climatologist. 

Huggard  ('06)  in  his  important  work  proposes  a  purely  physiologic 
basis  of  classification,  and  divides  climates  according  to  the  demands 
made  on  the  living  body  for  the  production  of  heat.  As  the  rate  of  heat 
production  is  the  surest  measure  of  the  activity  of  vital  metabolism,  the 
effect  on  this  function  is  obviously  the  most  important  physiologic  fea- 
ture of  climatic  action,  yet  Huggard's  classification  of  climates,  accord- 
ing to  this  single  principle,  although  most  illuminating,  is  probably  the 
most  complex  that  has  appeared.  As  a  matter  of  fact,  the  student  of 
medical  climatology  must  aim  to  learn  not  only  the  definite  physiologic 
reactions  to  definite  meteorologic  conditions,  but  also  the  empiric  bio- 
logic results  of  geographic  distribution.  In  therapeutic  practice  we  esti- 
mate the  complex  of  climatic  conditions  that  is  best  suited  to  a  definite 


CLASSIFICATION  OF   CLIMATES  667 

case,  and  then  select  that  resort  which  most  nearly  fulfills  the  physical 
demands,  after  due  consideration  of  its  accessibility,  social  surroundings, 
and  expensiveness. 

Our  choice  of  a  climate  for  an  invalid  is  usually  determined  by  our 
conception  of  the  total  demand  for  physiologic  reaction  made  by  tlie 
climate,  and  of  the  invalid's  capacity  to  respond  thereto.  According  to 
this  principle,  climates  may  be  divided  into  two  general  groups,  includ- 
ing (1)  those  which  are  sedative,  or  relaxing,  or  even  enervating,  (2) 
those  which  are  stimulating. 

The  main  meteorologic  factors  in  medical  climatology  are  tempera- 
ture and  humidity.  Their  relations  are  determined  by  distance  from  the 
equator,  distance  from  the  sea,  and  elevation  above  the  sea;  and,  in 
turn,  they  determine  the  weatiier  conditions  in  any  definite  locus. 

Dry  air  is  nearly  diathermanous.  The  sun's  heat  would  penetrate 
such  an  atmosphere  unimpeded,  and,  being  absorbed  by  the  soil,  would 
raise  its  temperature  accordingly.  In  a  dry  climate  a  solar  thermom- 
eter, an  instrument  with  blackened  bulb  suspended  in  vacuo,  may  show 
an  extraordinary  elevation  of  temperature  when  suspended  in  the  sun's 
rays,  but  a  peculiarly  low  degree  of  heat  when  moved  a  short  distance 
into  the  shade.  At  night  time,  the  earth  rapidly  returns  its  absorbed 
heat  by  radiation,  and  the  air  temperature  falls  very  low.  A  person 
exposed  to  the  sun's  rays  would  both  absorb  and  radiate  heat  rapidly; 
the  sensation  experienced  might  vary  from  one  of  comfortable  warmth 
to  intolerable  heat.  In  climates  where  such  conditions  are  approached 
it  is  possible,  with  shade  temperature  below  0°  F.,  to  sit  in  the  sun 
in  perfect  comfort  and  without  wraps.  To  him  who  sleeps  in  the  open 
air  in  summer,  the  nights  are  always  cool,  but  within  walls  which  have 
been  baked  throughout  the  glaring  day,  the  radiated  heat  may  be 
oppressive  for  many  hours. 

It  is  one  of  the  most  extraordinary  features  of  dry,  as  contrasted 
with  moist  climates,  that  the  range  of  sensible  as  compared  with  physi- 
cal temperatures  is  much  less  in  the  former  than  in  the  latter.  That 
is  to  say,  a  given  air  temperature  in  summer  in  a  dry  climate  would 
seem  much  less  oppressive  than  the  same  degree  of  heat  registered  in  a 
moist  atmosphere.  Conversely,  the  intensity  and  penetration  of  the  win- 
ter's cold,  as  measured  by  sensation,  is  definitely  increased,  at  a  given 
temperature,  by  the  amount  of  moisture  in  the  air. 

M.  W.  Harrington  ('93),  formerly  chief  of  the  United  States 
Weather  Bureau,  offered  an  explanation  of  these  facts  by  likening  the 
human  bod3%  in  its  reaction  to  temperature,  to  a  wet-bulb  thermometer. 
"  The  sensible  temperatures  depend  on  evaporation,  and  when  evapo- 
ration takes  place  they  are  invariably  lower  than  the  shade  temperatures 
given    in    meteorological    tables.  .  .  .  The    reduction    of    temperature 


668  THE    PHYSIOLOGY   OF   CLIMATE 

caused  by  evaporation  depends  on  the  rapidity  with  which  evaporation 
takes  place,  and  tliis  in  turn  on  the  amount  of  moisture  already  in 
the  air." 

Although  there  is  much  truth  in  this  aspect  of  the  subject,  unfor- 
tunately, as  pointed  out  by  Phillips  ('96),  the  problem  is  very  much 
more  complex  than  this  conception  would  indicate,  and  we  must  con- 
clude with  Phillips  "  that  for  the  time  being  we  have  no  index  of  sen- 
sible temperature,  and  the  use  of  the  indications  of  any  one  meteorologic 
instrument  for  such  purpose  can  only  give  under  the  most  favorable 
conditions  but  a  rude  approximation  to  the  truth,  and  too  remote  to  be 
of  much  practical  service." 

In  a  personal  communication  to  the  writer,  this  author  surmises  that 
the  nervous  irritability  of  the  skin  is  greatly  enhanced  by  moisture  in 
the  air,  and  vice  versa.  This  ingenious  idea  is  capable  of  explaining 
largely  the  want  of  parallelism  between  tlie  curves  of  sensible  and  physi- 
cal temperature. 

The  problem  is  evidently  one  of  psychology  as  well  as  physiology. 
Various  areas  of  a  person's  skin  may  give  the  same  subjective  tempera- 
ture sensation,  while,  measured  by  the  surface  thermometer,  they  ex- 
hibit widely  different  degrees  of  warmth.  The  facts  seem  to  indicate 
that  thermal  sensations  respond  to  finer  variations  of  a  temperature 
when  the  skin  is  moist  than  when  it  is  dry,  and  that  the  thermometric 
reading  which  corresponds  at  any  moment  to  physiologically  indifferent 
temperature  sensation  has  a  variable  value,  which  is  largely  dependent 
on  the  mean  of  nervous  reactions  which  have  preceded  the  period  of 
comparison. 

Huggard  ('06)  quotes  from  v.  Hmnboldt  practical  observations 
which  illustrate  this  subject :  "  We  had  not  yet  been  two  months  in  the 
hot  zone,  and  already  our  organs  were  so  sensitive  to  the  slightest  change 
of  temperature  that,  though  shivering  with  cold,  we  were  unable  to 
sleep,  and  to  our  astonishment  we  saw  that  our  thermometer  registered 
31.8°  C.  (71.24°  F.).  In  the  year  1803,  when  we  were  at  Guayaquil, 
the  natives  of  the  place  complained  of  cold  and  wrapped  themselves 
up  when  the  thermometer  fell  to  23.8°  C.  (74.84°  F.),  while  at  30.5° 
C.  (86.9°  F.)  they  found  the  heat  oppressive.  .  .  .  From  all  these 
observations  it  appears  that  in  low-lying  tropical  countries,  where  the 
temperature  by  day  is  almost  constantly  over  27°  C.  (80.6°  F.),  one 
finds  it  necessary  to  cover  oneself  up  at  night  whenever  in  this  moist 
air  the  thermometer  falls  four  or  five  degrees." 

It  is  usually  assumed  that  temperature  sensations,  so  far  as  they  are 
modified  by  moisture  in  the  air,  run  parallel  with  the  relative  humidity. 
This  physical  relation  no  doubt  regulates,  cceteris  paribus,  the  rate  of 
evaporation   of   moisture   from   the   skin,   as  from   any   other   surface; 


CLASSIFICATION   OF   CLIMATES  669 

nevertheless,  the  absolute  quantity  of  watery  vapor  in  the  air  cannot 
be  indifferent  to  the  skin  and  thermal  sensations.  Thus  in  the  arctic 
regions,  while  the  relative  humidity  is  very  high  on  account  of  the  very 
low  temperature,  "  the  air  is  almost  absolutel}^  dry,  and  yet  no  com- 
plaints are  heard  about  the  dryness  of  the  air  and  there  is  no  mention 
of  its  effects"  (Ham,  '03). 

The  living  body  loses  heat  chiefly  through  the  skin,  according  to 
the  activity  of  the  processes  of  radiation,  conduction,  evaporation,  and 
convection.  The  latter  factor  is  of  very  subsidiary  importance  in  still 
air,  but  in  moving  air  the  latter  two  phenomena  may  be  intensified  to 
such  a  degree  that  the  physiologic  relations  of  a  climatic  locus  may  be 
chiefly  determined  by  the  wind.  Gentle  breezes,  with  a  rate  of  move- 
ment between  five  and  ten  miles  an  hour,  probably  have  great  hygienic 
value,  both  in  purifying  the  air  and  in  acting  as  an  agreeable  physiologic 
stimulus.  But  strong  winds,  particularly  when  the  humidity  is  high 
and  the  temperature  low,  have  an  extraordinary  power  of  abstracting 
heat  from  the  body  and  producing  physiologic  chill.  A  moist  surface 
dries  most  quickly  in  a  current  of  hot,  dry  air;  but,  as  pointed  out  by 
Huggard  ('OG),  wind  does  not  greatly  increase  the  heat  loss  of  the  body 
to  dry,  warm  air,  but  it  greatly  accelerates  the  abstraction  of  heat  by 
cold  air,  especially  when  moist.  "  Clothing  gives  sufficient  protection 
against  dry,  but  not  against  moist,  cold  air." 

From  the  viewpoint  of  medical  climatology,  it  would  seem  that  the 
environment  capable  of  producing  the  highest  machine  efficiency  in  any 
definite  individual  would  be  one  in  which  the  physical  conditions  excite 
a  inaximal  mean  metabolism  in  all  the  living  tissues,  in  which  every 
physiologic  function  of  the  body  is  stimulated  to  its  full  capacity  of 
reaction.  The  range  of  physiologic  reaction  may  be  greatly  narrowed 
by  disease,  now  in  one  tissue,  now  in  another.  In  health  the  range  of 
vital  elasticity,  so  to  speak,  tends  to  continually  contract  with  disuse 
of  the  respective  function. 

In  the  hot,  moist  air  of  the  low-lying  tropics  the  mechanisms  of  heat 
elimination  are  exercised  to  the  maximum,  while  the  centers  of  heat 
production  receive  but  a  minimum  of  their  normal  stimulation ;  there- 
fore, as  cited  by  v.  Humboldt,  a  very  slight  fall  of  external  temperature 
surpasses  the  bounds  of  physiologic  accommodation  as  measured  by 
sensation.  On  the  contrary,  in  the  arctic  regions,  the  heat-producing 
apparatus  is  whi})ped  into  excessive  activity,  while  the  machinery  of 
heat  dissipation  is  in  very  languid  motion.  On  some  intermediate  iso- 
thermal lines  we  may  expect  to  find  a  set  of  physical  conditions  which, 
for  every  given  organism,  will  call  out  the  largest  reaction,  and  produce 
the  greatest  physiologic  efficiency  from  every  tissue  element  consonant 
with  the  full  coordination  of  that  element  with  its  neighbors. 


670  THE   PHYSIOLOGY   OF   CLIMATE 

It  has  been  pointed  out  that  isothermal  lines  eonstnicted  from  the 
readings  of  the  dry-  and  wet-bulb  thermometers  depart  widely  from 
parallelism.  Whatever  may  be  its  explanation^  there  is  no  doubt  that 
what  may  be  called  the  iso-aesthesodic  lines,  or  curves  of  sensation,  as 
concerned  with  temperature,  depend  more  especially  on  conditions 
which  determine  the  stand  of  the  wet-bulb  than  of  the  dry-bulb  instru- 
ment. If  this  be  true,  the  estimate  of  the  physiologic  reactions  induced 
by  a  given  climate  could  be  better  made  from  a  meteorologic  record  of 
humidities  than  of  temperatures  alone;  and,  manifestly,  supposing  a 
physical-physiologic  equation  to  have  been  constructed  from  these  data, 
the  element  of  wind  might  enter  and  at  once  destroy  the  balance  of 
the  terms. 

It  is  an  ideal  of  medical  climatology,  as  the  writer  conceives  it,  to 
trace  on  the  map  of  the  world  aesthesodic  and  kinesodic  curves,  the 
course  of  which  would  be  determined  by  the  integrated  reactions  of 
the  sensory  and  motor  functions,  respectively,  of  the  living  organism 
to  local  climatic  conditions.  Such  reactions  would  represent  the  phys- 
iologic mean  of  responses  from  all  the  individual  mechanisms  of  the 
body. 

The  aims  of  climatology,  stated  thus  abstractly,  are  actually  sought 
in  climatologic  practice.  For  example,  in  locating  a  patient  suffer- 
ing from  a  lesion  of  the  heart  or  kidney,  the  medical  adviser  seeks 
out  that  environment  in  which  he  conceives  the  physical  conditions  will 
throw  the  least  possible  strain  on  the  affected  organ.  And  in  dealing 
with  infections,  such  as  tuberculosis,  in  which  the  welfare  of  the  patient 
depends  on  the  sum  of  his  powers  of  "  vital  resistance,"  it  is  endeavored 
to  select  a  climate  which  shall  stimulate  to  the  utmost  the  forces  of 
physiologic  reaction,  considered  as  a  whole. 

So  complex  is  the  living  organism,  that  its  reactions  to  the  permu- 
tations of  the  meteorologic  elements  of  climate  cannot  possibly  be  de- 
duced from  known  principles.  Applied  medical  climatology  must  be 
built  on  a  broad  foundation  of  physiologic  experimentation,  harmonized 
with  carefully  sifted  empiric  observation. 

EFFECT    OF    EXCESSIVE    ILLUMINATION 

From  the  beginning  of  the  human  race,  light  has  been  a  symbol  of 
material  and  spiritual  good.  Universal  experience  confirms  the  results 
of  physiologic  and  bacteriologic  experiment,  which  prove  that  light  is 
indispensable  to  the  welfare  of  sentient  organisms,  and  unequaled  in 
destructive  effects  on  microbic  enemies  of  the  higher  beings.  Health 
resorts  generally  are,  to  a  large  extent,  valued  in  proportion  to  the  num- 
ber of  hours  of  actual  sunshine  recorded  in  them.     Nevertheless,  there  is 


HIGH   ALTITUDES  C71 

fair  presumption  that  tlie  intensit}'  of  illumination  may  easily  surpass  a 
degree  up  to  which  it  becomes  beneficial. 

Woodruff  ('05)  has  brought  together  a  considerable  array  of  facts 
to  supi^ort  the  hypothesis  that  members  of  northern  races,  especially 
individuals  having  blond  complexions,  suffer  materially  when  living 
in  the  tropics  from  intense  solar  illumination.  His  reasoning  is  based 
on  assumed  absorption  of  the  sun's  rays  by  the  blond  skin  and  excessive 
catabolism  induced  thereby.  The  pigment  in  the  skin  of  brunettes  and 
the  darker  races  more  or  less  eifectually  screens  the  living  tissues  from 
the  deleterious  radiations. 

Huggard  ('06)  dwells  on  the  element  of  temperature  as  determin- 
ing the  ability  of  races  to  bear  transplantation  to  foreign  lands.  "  As  a 
matter  of  fact,"  he  says,  "  a  man  becomes  acclimatized  readily  only  in 
countries  having  very  nearly  the  same  mean  temperature  as  the  coun- 
try to  which  his  race  belongs.  Individuals  may  live  in  seeming  health 
in  climates  much  hotter  or  colder  than  their  own.  But  their  posterity 
does  not  fare  equally  well ;  their  descendants  melt  away,  and  hardly  a 
survivor  remains  to  the  third  or  fourth  generation.  The  attempt  to 
colonize  directly  a  land  having  a  mean  temperature  widely  different 
from  that  of  the  native  land  of  the  colonists  has  always  ended  in  fail- 
ure." It  is  very  probable  that  the  factor  of  illumination-intensity  plays 
an  important  part  in  the  ruling  influence  of  insolation,  as  described  by 
Huggard. 

According  to  Woodruff  ('05),  the  deleterious  influence  of  strong  sun- 
light in  the  tropics  is  manifested  especially  on  the  nervous  system,  and 
leads  to  neurasthenia  and  associated  disorders.  This  author's  ideas, 
if  true,  should  be  of  great  value  to  the  medical  climatologist  as  a  guide 
to  a  therapeutic  selection  of  climates,  not  only  according  to  the  com- 
plexion but  the  temperament  of  his  patients.  But  the  problem  is  evi- 
dently much  more  complex  than  the  presentation  of  Woodruff  would 
indicate. 

HIGH    ALTITUDES 

The  factors  of  temperature  and  humiJity  probably  have  much  to  do 
with  increasing  the  sensitiveness  of  the  skin  to  the  luminous  rays,  and, 
above  all,  the  equability  of  temperature  and  moisture,  when  their  degree 
is  high,  must  be  potent  as  a  cause  of  vital  debility.  Eesidence  at  high 
altitudes  should,  according  to  the  assumption  of  Woodruff,  furnish  the 
prime  conditions  for  the  develoj^ment  of  the  neurasthenic  state.  For  in 
such  resorts  the  sunlight  is  unrivaled  in  strength  and  duration,  and 
especially  rich  in  the  very  refrangible  rays  which  are  kno^^^l  to  chiefly 
affect  metabolism  in  the  skin,  while  at  the  same  time  the  air  is  dry 
and  cool. 


672  THE   PHYSIOLOGY   OF  CLIMATE 

"V\liile  it  is  generally  admitted  that  invalids  of  nervous  temperament 
are  apt  to  do  badly  at  even  moderately  high  altitudes,  and  that  most 
persons,  especially  females,  feel  a  need  of  change  after  prolonged  resi- 
dence under  such  conditions,  it  is  improbable  that  any  one  factor  is  of 
predominant  importance  in  producing  this  effect.  An  experience  of  over 
seventeen  years  in  Denver,  near  the  fortieth  parallel  of  latitude  and  at 
one  mile  above  sea  level,  where  the  sunshine  in  winter  is  sixty-two  per 
cent  of  a  possible  monthly  mean  of  one  hundred  and  eighty-eight  hours, 
convinces  the  writer  that  the  brightness  of  a  winter's  day  induces  an 
exhilaration  which  rather  increases  than  decreases  as  the  years  go  by. 
Neither  can  he  recall,  among  the  considerable  number  of  pulmonary 
invalids  that  have  come  under  his  observation,  any  special  relation  of 
complexion  to  susceptibility  to  light,  nor  manifest  bearing  of  this  con- 
stitutional trait  on  the  course  of  disease  under  conditions  of  high 
illumination. 

The  pliysiologic  effects  of  the  various  elements  of  climate  have  been 
determined  chiefly  by  a  study  of  extreme  conditions.  It  is  as  if  the 
therapeutic  action  of  a  series  of  drugs  were  required  to  be  deduced 
from  their  toxic  powers.  The  beneficial  results  of  the  open-air  treat- 
ment in  tuberculosis  have  especially  impressed  on  medical  climatology 
the  truth  that  the  physiologic  response  of  the  organism  to  change  in 
environment  is  determined  by  very  delicate  reactions.  Of  two  similar 
invalids  in  this  class,  the  one  housed  in  an  ordinary  bedroom,  well 
warmed  and  windows  closed,  and  the  other  resting  under  like  condi- 
tions, but  just  outside  the  wall  of  the  house,  protected  only  from  high 
winds,  rain,  and  extremes  of  temperature,  the  probabilities  would  gi-eatly 
favor  the  recovery  of  the  latter  as  compared  with  the  former  patient. 
Climatic  therapy  is  founded  on  observations  of  this  nature. 

Of  late  years  tlie  advance  of  medical  climatology  has  received  its 
chief  stimulus  through  a  study  of  tlie  physiologic  reactions  incident  to 
life  in  high  altitudes.  Systematic  observations  and  experiments  by 
trained  physiologists,  beginning  in  the  laboratory  of  Paul  Bert  ('78) 
and  leading  up  to  the  recent  researches  on  Monte  Eosa,  conducted  by 
the  party  headed  by  Zuntz  and  Loewy  ('06),  go  far  toward  giving  medi- 
cal climatology  a  foundation  in  exact  knowledge. 

High  climates  in  temperate  latitudes  embrace  the  special  characters 
of  widely  different  regions,  with  added  qualities  peculiar  to  themselves. 
There  are  found  the  intense  illumination  of  the  tropics,  but  the  low 
humidity  and  variable  temperature  of  inland  deserts.  Though  the  heat 
of  the  air,  as  measured  by  the  thermometer,  rapidly  passes  through  wide 
variations,  the  sensible  temperature  may  apparently  oscillate  less  largely 
than  under  the  equable  conditions  of  a  sea  coast.  In  addition,  the  rare- 
faction of  the  atmosphere  induces  a  special  chain  of  physiologic  reac- 


HIGH  ALTITUDES  673 

tions  unparalleled  by  any  other  climatic  environment.  The  monograph 
of  Ziintz  and  his  collaborators,  which  has  already  been  reviewed  by  the 
writer  (Sewall,  '04),  forms  an  admirable  basis  for  the  discussion  of  the 
vital  effects  of  lowered  barometric  pressure. 

The  futility  of  attempting  to  deduce  the  nature  of  physiologic  reac- 
tions from  a  knowledge  of  the  mechanical  conditions  involved  is  well 
illustrated  in  this  field  of  study. 

Xearly  a  century  and  a  quarter  ago  the  great  physiologist,  Albrecht 
V.  Haller,  originated  the  "  cupping-glass  "  theory  of  the  effects  produced 
on  the  circulation  in  the  living  through  diminution  of  atmospheric 
pressure.  That  idea  has  continued  to  cling  to  the  mind  of  student 
and  layman  alike.  The  facts  of  "  caisson  disease,"  a  disorder  produced 
by  too  sudden  decompression  after  a  sojourn  in  highly  condensed  air, 
are  proof  positive  that  gases  dissolved  in  the  body  fluids  may  be  liber- 
ated with  destructive  effects  when  the  air  tension  on  the  surface  of  the 
body  is  suddenly  diminished  to  a  sufficient  degree,  very  much  as  a 
bottle  of  aerated  water  froths  when  the  cork  is  withdrawn.  Most  com- 
petent observers  (Hill,  '07)  appear  to  agree,  however,  that,  under,  ordi- 
nary conditions  of  changing  atmospheric  pressure,  the  variations  are  so 
gradual  that  that  equilibrium  between  internal  and  external  air  ten- 
sions is  practically  continuous.  Nevertheless,  the  clinical  observer  at 
high  altitudes  is  frequeftitly  impressed  with  facts  which  seem  to  confirm 
the  conclusions  of  H.  Kronecker  ('03). 

According  to  this  author,  the  lowering  of  atmospheric  pressure  exer- 
cises an  effect  on  the  distribution  of  blood  in  the  body  in  such  a  man- 
ner as  to  cause  a  relative  accumulation  in  those  superficial  vessels  which 
have  the  least  mechanical  support ;  such  are  evidently  the  blood-vessels 
of  the  lungs.  Therefore  diminution  of  atmospheric  pressure  would 
lead  to  pulmonary  congestion  and  a  tendency  to  stagnation  of  blood  in 
the  lungs. 

There  is,  unfortunately,  still  wanting  crucial  demonstration  of  the 
facts  pertaining  to  the  distribution,  rate  of  movement,  and  pressure 
values  of  tlie  blood  as  influenced  by  air  density.  Wlien  the  lungs  are  at 
rest  and  the  glottis  is  open,  the  air-pressure  within  the  pulmonary  alve- 
oli is  probably  practically  identical  with  that  on  the  surface  of  the  body, 
and  the  tension  of  the  l)lood  gases  very  rapidly  reaches  the  same  value. 
Tins  mechanical  equilibrium  would  exist,  under  the  same  conditions,  at 
all  altitudes  tolerable  to  life.  At  the  onset  of  an  inspiratory  movement, 
however,  there  is  at  once  a  fall  in  the  tension  of  the  alveolar  air,  and 
the  pressure  on  and  within  the  body  at  large  remaining  the  same, 
the  expanding  walls  of  the  thorax  act  like  a  veritable  cupping  glass, 
drawing  blood  into  the  riglit  heart  and  hmgs.  The  lack  of  tissue  sup- 
port about  the  pulmonary  capillaries,  their  remarkable  distensibility 
44 


674  THE   PHYSIOLOGY   OF   CLIMATE 

and  possible  freedom  from  vasomotor  control,  puts  these  vessels  pecul- 
iarly at  the  mercy  of  mere  mechanical  disturbances. 

No  diminution  of  atmospheric  pressure  affecting  simultaneously  the 
skin  and  pulmonary  alveoli  sliould  be  expected  to  cause  a  translation 
of  the  incompressible  body  fluids,  simply  because  the  pressure  is  uni- 
formly distributed.  Pent-up  gases,  as  found  in  the  abdominal  viscera, 
expand  under  such  conditions  according  to  known  physical  laws,  and  by 
upward  distention  of  the  diaphragm  may  cause  symptoms.  Again,  if 
the  fall  of  external  air-pressure  were  extensive  and  rapid  enough,  blood 
gases  would  be  thrown  out  of  solution  and,  in  the  following  lines  of 
least  resistance,  might  produce  movements  in  the  blood  mass. 

There  is,  liowever,  an  easy  physiologic  explanation  of  the  physical 
disturbances  in  the  pulmonary  circulation  encountered  under  condi- 
tions of  lowered  barometric  pressure.  Such  a  change  causes  an  increase 
in  the  depth,  and  usually  in  the  rate  of  breathing.  Therefore  the  me- 
chanical force  which  drives  blood  to  the  lungs  is  proportionately  in- 
creased. But  at  the  same  time  it  is  extremely  probable  that,  under 
usual  conditions,  the  coordination  of  the  complex  mechanisms  of  circu- 
lation and  respiration  is  impaired  so  that  the  heart  is  unable  to  empty 
itself  efficiently. 

The  evidence  that  heart  strain  may  easily  be  induced  in  high  alti- 
tudes, particularly  under  conditions  of  muscular  exertion,  is  founded 
both  on  common  experience  and  scientific  observation.  Professor  Zuntz 
and  his  colleagues  especially  call  attention  to  the  insidious  onset  and 
progress  of  cardiac  dilatation  under  such  conditions. 

This  incapacity  is  manifested  in  persons  who  are  unaccustomed  to 
conditions  of  lowered  barometric  pressure.  As  a  result  of  training 
and  during  the  process  of  acclimatization,  physiologic  coordination  is 
reestablished.  Thereafter  relative  pulmonary  congestion  is  only  to  be 
expected  especially  at  high  altitudes,  because,  as  will  be  pointed  out 
later,  under  such  conditions  relatively  slight  exertions  are  apt  to  load 
the  lungs  with  blood  faster  than  the  heart  can  discharge  it.  It  is  clear 
that,  though  the  left  ventricle  may  considera1)]y  increase  its  output,  the 
excessive  ratio  of  inflow  to  the  riglit  lieart  would  soon  lead  to  distention 
of  this  viscus  and  to  the  distress  of  cardiac  dyspnea. 

Paul  Bert  ('78),  in  his  encyclopedic  work  on  the  physiologic  influ- 
ence of  barometric  pressure,  furnished  the  first  evidence  that  life  in 
high  climates  modifies  the  oxygen-carrying  function  of  the  blood  when 
he  showed  that  the  blood  of  animals  habituated  to  very  high  altitudes 
contained,  per  volume,  considerably  more  oxygen  than  that  of  creatures 
living  in  the  lowlands.  For  a  decade  the  importance  of  Bert's  researches 
was  insufficiently  recognized,  but  Viault  ('90;  '91;  '91  A;  '92).  during 
observations  made  in  the  Cordilleras  at  an  altitude  of  about  14,000  feet. 


HIGH  ALTITUDES  675 

found  that  at  this  elevation  his  red  blood  cells  numbered  about  8,000,000 
per  cubic  millimeter,  whereas  three  weeks  before,  at  sea  level,  the  count 
was  but  5,000,000.  A  similar  polycythemia  marked  the  blood  of  people 
who  had  lived  at  the  high  level  since  birth. 

Herein  was  furnished  the  tirst  positive  evidence  that  residence  in 
high  climates  produced  a  definite,  tangible  change  in  the  living  organ- 
ism. A  considerable  literature  has  since  been  built  on  this  thesis,  of 
Avhich  admirable  and  critical  summaries  may  be  found  in  the  works  of 
Zuntz  ('OG)  and  of  Tissier  ('06). 

Of  the  increase  in  the  red  Ijlood  count  as  a  result  of  ascent  above 
sea  level  there  can  be  no  doubt.  The  only  question  at  issue  concerns 
the  meaning  of  the  polycythemia,  whether  it  is  due  to  a  real  increase 
in  the  number  of  blood  corpuscles  throughout  the  body  or  simply  to  a 
redistribution,  which  leads  to  turgescence  of  the  superficial  vessels  from 
which  the  enumeration  is  usually  made.  In  favor  of  the  latter  explana- 
tion are  evidences  that  the  conditions  in  high  climates  induce,  at  least 
in  unacclimated  persons,  the  accumulation  of  blood  corpuscles  in  the 
vessels  of  the  skin.  Moreover,  the  increase  of  blood  count  with  ascent, 
and  its  decrease  with  descent,  follow  almost  immediately  the  changes 
in  elevation.  It  is  hardly  conceivable  that  the  processes  of  blood  for- 
mation and  destruction  could  be  stimulated  to  such  a  rate.  Again, 
Ambard  (Tissier,  '06),  experimenting  with  dogs  confined  in  pneumatic 
boxes,  showed  that  even  when  the  barometric  pressure  was  reduced  to 
450  mm.  Ilg.,  tlie  blood  in  the  femoral  artery  contained  per  volume 
rather  fewer  blood  cells  than  at  normal  air-pressure. 

Investigations  by  Campbell  and  Hoagland  ('01)  on  Pike's  Peak,  in 
Colorado,  and  similar  researches  in  the  high  Alps  (Zuntz,  et  ah,  '06), 
have  sliown  that  in  the  ral)bit,  blood  from  the  ear  vessels  contains  a 
considerably  larger  proportion  of  corpuscles  than  that  taken  from  the 
internal  organs.  In  the  lowlands  no  such  difference  is  manifest. 
Xevertliolcss,  trustworthy  ol)servations  support  the  conclusion  that  rare- 
faction of  the  air  does,  in  fact,  act  as  a  specific  stimulus  to  the  cytogenic 
function  of  the  bone  mariow,  leading  both  to  increase  in  the  number 
of  erythrocytes  and  in  the  amount  of  hemoglobin  in  the  body. 

The  ])iologic  reaction  leading  to  this  result  develo|)s  gradually,  and 
])robably  reaches  its  maximum  after  a  variable  interval,  it  may  Ijc  of 
several  weeks.  Individuals  differ  greatly  in  the  susceptibility  of  their 
hemapoictic  tissues  to  the  stimulus  of  rarefied  air;  young  animals  con- 
stantly show  a  greater  relative  polycythemia.^ 

'  Of  interest  in  this  direction  are  the  recent  findings  of  Webb  and  Wilh'ams 
('09)  of  ;iii  incroaso  in  tlio  number  of  lymphocytes  in  hijili  altitude.  If  oonfirmed 
this  may  explain,  at  least  partly,  the  beneficial  effect  of  hi^li  altitude  in  tul)eiculosis, 
— Editcjr. 


676  THE   PHYSIOLOGY   OF   CLIMATE 

Most  suggestive  from  a  theoretic,  and  valuable  from  a  clinical,  stand- 
point, are  the  observations  conducted  by  Professor  Zuntz  and  his  party 
on  what  may  be  termed  the  physiology  of  acclimatization. 

The  sharply  marked  vital  reactions  which  occur  as  result  of  removal 
to  sufficiently  high  elevations,  and  which  may  be  made  to  vary  quanti- 
tatively according  to  the  altitude,  give  to  the  study  of  high  climates 
a  peculiar  biologic  interest.  It  has  been  shown  that  in  an  ascent  from 
the  level  of  the  sea  the  activity  of  the  blood-forming  organs  is  increased. 
According  to  the  curve  constructed  by  de  Bouaille,  the  red  blood  cor- 
puscles increase  rapidly  in  number  up  to  the  altitude  of  about  0,500 
feet,  then  more  slowly  to  13,000  feet,  and  afterwards  very  slowly 
indeed. 

When  we  inquire  as  to  the  nature  of  the  stimulus  which  excites  this 
modification  in  metabolism,  attention  is  necessarily  directed  to  the  low- 
ered oxygen  tension  of  rarefied  air.  The  most  trustworthy  observations 
and  experiments  seem  to  lead  to  the  conclusion  that  relative  oxygen 
deficiency  in  the  air  is  the  cause  of  the  major  physiologic  reactions  to 
lowered  barometric  pressure.  Laboratory  experiments  show  that  when 
shed  blood  is  placed  under  the  receiver  of  an  air  pump,  oxygen  does 
not  begin  to  break  loose  from  its  combination  with  hemoglobin  until 
the  air-pressure  has  been  reduced  to  300  mm.  Hg.,  which  corresponds 
to  the  barometric  pressure  at  an  elevation  of  17,000  feet  above  sea  level 
(Foster,  '89). 

Many  of  the  physiologic  disturbances  under  discussion  become  well 
marked  at  less  than  half  this  altitude,  where  the  partial  pressure  of 
oxygen  in  the  air  is  amply  sufficient  to  saturate  the  blood,  provided  the 
physiologic  mechanisms  are  able  to  appropriate  and  distribute  it  to  the 
vital  tissues.  For  the  present  we  must  be  content  to  explain  the  facts 
by  analogy.  Facility  in  any  feat  of  skill  requires  the  development  by 
practice  of  new  coordinations  of  the  nerve-muscle  functions.  The  very 
processes  of  secretion  and  digestion  are  specifically  related  to  the  nature 
of  the  aliment,  and  can  be  prostrated  completely  by  a  sudden  radical 
change  in  the  character  of  the  food. 

The  absorption  of  oxygen  by  the  lungs,  and  its  distribution  to  and 
appropriation  by  the  tissues,  is  a  chain  of  vital  events  not  to  be  ex- 
plained by  the  laws  of  physics  alone.  Therefore,  although  the  oxygen 
in  the  air  at  an  altitude,  say,  of  10,000  feet,  is  amply  sufficient  to  supply 
the  necessities  of  the  body,  it  is  not  strange  that  the  living  protoplasm 
should  show  some  disturbance  in  adjusting  itself  to  the  reduction  in  the 
physical  aid  to  absorption  to  which  it  had  been  habituated.  It  is  self- 
evident  that  a  physiologic  adjustment  which  compensates  a  lowered 
oxygen  pressure  while  the  body  is  at  rest  may  at  once  be  thrown  out 
of  balance   through   the    demands   of   muscular   exertion.      Thus   it   is 


HIGH   ALTITUDES  077 

found  to  be  a  constant  fact  that  exercise  in  high  climates  produces  a 
greater  relative  rapidity  of  heart  action,  respiration,  and  general  metab- 
olism than  is  involved  in  the  same  expenditure  of  physical  energy  in 
the  lowlands. 

The  physiologic  waste  of  energy  is  inversely  proportional  to  the  grade 
of  acclimatization  of  the  individual.  It  cannot  be  too  strongly  empha- 
sized that  removal  from  a  lower  to  a  higher  climate  demands  from  the 
vital  powers  an  extension  of  their  coordinations.  So  imperative  is  this 
demand  that  the  very  structure  of  the  body  is  altered  in  response  to  it. 
The  increased  hematopoiesis  at  high  altitudes  has  already  been  dis- 
cussed. The  work  of  Zuntz  ('06)  and  his  collaborators  demonstrates, 
in  addition,  the  extraordinary  fact  that  in  moderately  high  altitudes 
metabolism  is  so  modified  that  there  is  a  laying  on  of  proteid  material, 
even  in  persons  of  adult  age — a  fact  without  parallel  in  medical  clima- 
tology. This  modification  of  nutrition  may  still  further  progress  after 
the  person  under  observation  has  returned  to  a  lower  level.  This  fact 
furnishes  an  interesting  physical  basis  for  the  long  persisting  benefit 
from  a  temporary  sojourn  in  the  mountains. 

Healthy  people  may  passively  ascend  to  considerable  elevations  with- 
out sensible  disturbance  of  function;  but  even  slight  exertion,  such  as 
walking  a  few  steps,  is  apt  at  once  to  excite  disturbance  of  circulation 
and  respiration,  or,  in  extreme  cases,  precipitate  the  remarkable  chain 
of  events  involved  in  "  mountain  sickness."  When  invalids  seek  the 
higher  climates,  the  deleterious  effects  of  overstrain  of  the  vital  powers 
are  apt  to  outlast  the  act,  and  later  cause  disaster,  A  heart  which  is 
intrinsically  weak  is  liable  to  dilate  so  gradually  under  the  overloading 
induced  by  exertion  that  a  fatal  strain  is  experienced  without  the  victim 
realizing  its  onset.  Herein,  probably,  is  the  explanation  of  the  not 
infrequent  fatalities  occurring  among  patients  with  pulmonary  tubercu- 
losis, who  think  they  may  venture  on  their  customary  exercise  directly 
on  coming  to  a  higher  altitude.  Such  persons  sometimes  unnecessarily 
go  to  pieces  with  symptoms  of  acute  pulmonary  edema,  precipitated, 
it  may  be,  by  very  slight  exertions.  The  bright  sunshine  and  the  crisp, 
dry  air  at  high  elevations  are  stimuli  which  primarily  excite  the  ner- 
vous system,  and  indulgence  in  a  motor  response  which  is  proportionate 
to  the  sensory  stimulation  is  prone  to  overtax  the  vital  powers.  The 
physiologic  response  to  the  physical  conditions  encountered  in  high 
climates  throws  special  strain  on  the  sensory  and  coordinating  tissue — 
the  nervous  system. 

We  find  in  experience,  what  might  have  been  expected  from  theory, 
that  persons  of  unstable  nervous  temperaments  are  apt  to  have  their 
morbid  symptoms  exaggerated  at  high  altitudes.  Clinical  experience 
shows,  however,  that  with  freedom  from  excitement  and  exercise  and 


678  THE    PHYSIOLOGY   OF   CLIMATE 

proper  manipulation  of  the  factors  of  irritation,  there  is  often,  in  such 
cases,  to  be  achieved  the  good  without  the  ill  effects  of  life  at  high 
levels. 

It  has  been  abundantly  demonstrated  that  the  physiologic  effects 
of  high  altitudes  are  such  as  indicate  stimulation  of  all  vital  functions 
with  an  intensity  whose  maximum  is  very  high  and  whose  range  may  be 
wide.  Acclimatization  consists  in  the  development  of  physiologic  coor- 
dinations within  wider  limits  than  usual,  as  well  as  in  anatomic  growth 
of  the  tissues  which  must  chiefly  bear  the  burden  of  excessive  function. 
Careful,  gradual  preparation  of  the  powers  preliminary  to  ordinary  ex- 
ertions at  high  altitudes  is  as  important  an  aid  to  acclimatization  as  is 
the  course  of  training  found  necessary  by  an  athlete  before  entering 
on  a  physical  contest.    . 

Practical  medical  climatology  seeks  to  define  the  climatic  conditions 
which  Avill  favor  the  development  of  maximum  machine  efficiency  from 
the  physiologic  functions  of  the  body,  taken  as  a  whole,  in  men  of 
every  variety  of  constitution.  It  is  important  to  bear  in  mind  that,  as 
in  human  society,  so  in  the  community  of  cells  forming  an  organism,  the 
optimum  activity  of  each  individual  element  which  contributes  to  the 
best  interests  of  the  l)ody  as  a  whole  is  that  through  which  it  gives 
the  utmost  help  to  the  purposes  of  its  associated  neighbors;  or,  in  the 
language  of  field  sports,  it  is  only  through  "  team  work  "  that  an  aggre- 
gation becomes  a  successful  unit.  Therefore,  in  making  a  climatic 
prescription  for  a  definite  individual,  the  medical  adviser  considers  the 
interests  of  the  weakest  function  to  be  paramount.  A  debilitated  heart 
or  kidney  may  need  as  thorough  relief  as  possible  from  the  exigencies 
of  its  functions ;  accordingly,  in  such  a  case  it  is  usually  sought  to  fix 
on  a  climate  characterized  by  a  moderate  and  equable  temperature,  a 
fair  amount  of  humidity,  and  an  environment  offering  stimuli,  of  what- 
ever sort,  varying  in  frequency  and  intensity  only  sufficiently  to  keep 
the  mind  pleasantly  interested.  These  are  the  physical  conditions  con- 
stituting what  is  termed  a  sedative  climate. 

i^ccording  to  the  nature  and  range  of  intensity  of  physical  stimuli 
involved  in  the  environment,  the  physiologic  effect  may  vary  from  tonic 
and  bracing  to  one  promoting  lassitude.  On  the  other  hand,  in  chronic 
s3^stemic  infections,  such  as  tuberculosis,  whose  cure  is  founded,  appar- 
ently, on  the  products  of  vital  reactions  of  living  tissues  to  stimulation, 
experience  confirms  the  theory  that,  midatis  mutandis,  the  most  favorable 
environment,  such  as  an  outdoor  life,  is  one  in  which  the  physiologic  re- 
sponse of  the  vital  tissues  is  pushed  toward  an  extreme.  Such  conditions 
determine  the  stimulating  climates,  especially  as  manifested  in  resorts 
at  high  altitudes. 


THE   PRINCIPLES  OF   PHYSIOLOGIC   REST  679 

In  the  infinite  variety  of  more  or  less  morl)id  conditions  which  de- 
pend on  general  vital  depression  from  too  continuous  effort,  or  when 
there  is  debility  of  one  or  another  of  the  vital  functions  without  distinct 
disease,  the  safest  climatic  therapeutic  advice  is  founded  on  the  known 
psychic  effects  of  geographic  change. 

THE    PRINCIPLES    OF    PHYSIOLOGIC    REST 

While  nothing  is  more  certain  tlian  that  tlie  functioning  powers  of 
an  organism  demand  for  their  development  exercise  in  overcoming  re- 
sistances, nevertheless  therapeutic  experience  has  established  the  truth 
that  in  many  morbid  conditions  the  only  safety  for  the  individual  is 
to  be  found  in  a  condition  approaching  absolute  rest. 

In  local  septic  infections  it  is  easy  to  see  how  muscular  contraction, 
with  its  attendant  acceleration  of  tlie  circulation,  can  disseminate  the 
materies  morhi  and  poison  the  whole  body.  Though  even  in  this  sim- 
plest case  the  rationale  of  successful  treatment  is  obscure  enough,  the 
general  principle  is  clear  that  the  healthy  organism,  undisturbed  by 
functional  demands,  has  extraordinary  power  to  remedy  purely  local 
evils  in  its  various  parts.  Indeed,  the  very  fact  of  its  existence  is  crucial 
evidence  that  a  given  organism  is  endowed  with  a  power  of  constructive 
metabolism  sufficient  to  have  overcome  innumerable  assaults  of  opposing 
forces. 

When  we  recognize  the  importance  of  physical  rest  as  an  aid  to  the 
"  resistance  "  powers  of  the  body  in  its  struggle  with  infectious  disease, 
it  is  not  difficult  to  believe  that  in  those  intricate  disorders  arising  from 
maladministration  of  its  nervous  and  psychic  forces  the  broader  princi- 
ples of  physiologic  rest  must  be  invoked  to  accomplish  a  cure.  Lombard, 
in  measuring  a  series  of  knee-jerks,  has  shown  that  the  height  of  the 
contraction  is  at  once  increased  when  a  sound,  so  faint  as  not  to  be 
consciously  perceived  by  the  subject,  breaks  the  stillness  of  the  air.  This 
is  a  concrete  example  of  what  is  doubtless  a  general  truth  that  every 
known  physical  agent,  not  to  mention  unknown  forces,  inevitably  ex- 
cites the  sensorium  when  of  sufficient  intensity  to  cross  the  threshold 
of  irritability  of  the  peripheral  afferent  nerves.  These  stimuli,  more- 
over, invariably  overflow  from  the  recipient  sensory  centers,  and  radiate 
in  currents  of  greater  or  less  intensity  throughout  the  motor  and  cen- 
trifugal districts  of  the  nervous  system.  It  is  capable  of  satisfactory 
demonstration  that  such  conscious  and  subconscious  stimuli  may  operate 
as  pathologic  irritants,  for  they  exert  upon  the  nervous  system  essentially 
the  same  disastrous  influence  as  does  physical  exercise  upon  the  inflamed 
or  infected  tissues  at  large.  While  it  is  relatively  easy  to  secure  pos- 
tural quietude  through  the  so-called  "rest  treatment,''   it  would  seem 


680  CLIMATIC  THERAPEUTICS 

impossible  to  prevent  the  coruscations  of  sensory  impulses  throughout 
a  hyperirritable  nervous  system. 

Nevertheless,  the  therapeutist  finds  that  Nature  has  provided  for  her 
kinetic  energies  a  balance  which  we  know  as  Inhibition,  through  which 
activity  may  be  restrained,  conserved,  or  annulled.  It  is  evident  that 
this  field  of  his  labor  has  become  that  of  ps3Thology,  and  the  assertion 
may  jferhaps  be  ventured  that,  through  the  application  of  what  may 
crudely  be  included  under  the  term  "  suggestion,"  the  forces  of  inhibition 
may  be  aroused  to  restrain  and  direct  the  dispersive  energies  of  the 
neurons.  The  marvelous  clinical  rehabilitations  which  are  daily  placed 
to  the  credit  of  "  psychic  "  ministrations  represent  nothing  more  than 
the  superiority  of  the  inherent,  sustaining,  conservative  resisting  powers 
of  protoplasm  when  freed  from  what  may  be  called  adventitious  vital 
friction.  In  short,  functional  metabolism  throughout  the  body  has  an 
unmeasured  range  of  adaptability  to  its  normal  tasks  when  freed  from 
aberrant  nervous  impulses.  Such  freedom  constitutes  rest.  On  reflec- 
tion it  is  clear  that  rest  in  the  sense  here  involved  is  not  different  in 
kind  from  that  exercise  whose  energy  is  not  lost  in  friction,  but  is 
directed  to  functional  uses. 


CLIMATIC  THERAPEUTICS 
By  W.  JARVIS  BARLOW 

HISTORICAL    ASPECTS 

It  is  interesting  to  read  the  translations  from  the  Greek  and  Latin, 
and  note  how  much  the  ancient  authorities — Hippocrates,  Galen,  Celsus, 
and  Paulus  ^Eginetes — studied  the  conditions  and  factors  of  climate,  and 
their  effect  on  epidemic  and  chronic  diseases,  their  views  on  the  air 
of  various  places,  the  water,  dust,  soil,  and  so  on.  Hippocrates,  the 
father  of  medicine  (470  B.C.),  speaking  of  air,  water,  and  places,  says: 
"  Whoever  wishes  to  investigate  medicine  properly  should  proceed  thus : 
In  the  first  place,  to  consider  the  seasons  of  the  year  and  what  effects 
each  of  these  produces  (for  they  are  not  at  all  alike,  but  differ  each 
from  themselves,  in  regard  to  their  changes)  ;  then  the  winds,  the  hot 
and  the  cold,  especially  such  as  are  common  to  all  countries,  and  then 
such  as  are  peculiar  to  each  locality.  You  must  also  consider  the  quali- 
ties of  the  waters,  for  as  they  differ  from  one  another  in  taste  and 
weight,  so  also  do  they  differ  much  in  their  qualities."  He  also  lays 
emphasis  on  the  situation  of  the  town  or  city  in  respect  to  the  prevailing 
winds,  the  rising  sun,  and  the  amount  of  sunshine.     In  the  matter  of 


HISTORICAL  ASPECTS  681 

soil,  he  says  that  one  should  understand  and  be  particular  whether  the 
place  is  marshy,  well  wooded,  and  has  a  sufficient  water  supply,  and  that 
by  knowing  these  things  one  will  not  be  in  doubt  as  to  the  treatment 
of  disease,  or  make  as  many  mistakes  as  if  he  had  not  been  in  possession 
of  this  knowledge. 

Among  the  aphorisms  of  Hippocrates  which  were  discussed  by  Galen 
and  others  there  are  announcements,  true  in  all  ages,  that  are  generally 
accepted  in  modern  times.  Some  apply  to  special  climatic  therapeutics. 
"  The  changes  of  the  season  most  engender  diseases,  and  in  the  seasons 
great  changes  either  of  heat  or  of  cold,  and  the  rest  agreeably  to  the 
same  rule."  "  Of  natures  (temperaments?),  some  are  well  or  ill  adapted 
for  summer  and  some  for  winter."  ISothing  can  be  truer  than  this  in 
our  modern  teaching.  "  Of  diseases  and  ages,  certain  of  them  are  well 
or  ill  adapted  to  different  seasons,  places,  and  kinds  of  diet."  "  Of  the 
constitutions  of  the  year,  the  dry,  upon  the  whole,  are  more  healthy 
than  the  rainy,  and  attended  with  less  mortality."  "  Autumn  is  a  bad 
season  for  persons  in  consumption."  "  The  spring  is  most  healthy  and 
least  mortal."  Althougli  these  aphorisms  were  written  many  years  be- 
fore Christ,  nothing  truer  can  be  said  to-day. 

A.  Cornelius  Celsus,  born  25  B.C.,  whose  medical  writings  in  Latin 
are  so  well  knowTi,  in  speaking  of  phthisis  stated :  "  But  if  the  distemper 
is  more  violent,  and  there  is  a  true  phthisis,  it  is  necessary  to  oppose 
its  beginnings,  for  if  this  distemper  continues  long,  it  is  not  easily 
overcome.  If  the  patient's  condition  allow,  he  must  take  a  long  sea 
voyage,  change  his  climate,  taking  care  to  remove  to  a  grosser  one  than 
that  he  leaves,  and  therefore  from  Italy  to  Alexandria  is  a  very  agree- 
able change.  ...  If  the  weakness  will  not  admit  of  that,  it  is  very 
proper  to  sail  in  a  ship,  but  not  too  far;  but  if  any  circumstances  ren- 
der the  sailing  unfit,  the  body  must  be  moved  on  a  litter  or  some  other 
way.  ..." 

Paulus  zEgineta,  who  wrote  in  the  seventh  century  after  Christ, 
laid  special  emphasis  on  pure  air  and  the  fact  that  the  different  qualities, 
such  as  heat,  cold,  dryness,  or  humiditj^  have  not  the  same  effect  on 
all;  that  it  is  a  matter  of  temperament  with  regard  to  the  benefit 
derived. 

Thus  it  is  seen  that  not  only  a  change  of  surroundings,  but  a  change 
of  climate,  Avas  recommended  in  the  earliest  records.  Often  the  benefit 
that  such  change  brought  to  the  patients  was  attributed  to  nonatmos- 
pheric  elements.  Springs  were  frequently  sought  for  their  mineral 
effects,  agricultural  districts  for  their  dairy  products,  vicinities  of  for- 
ests for  their  healing  qualities.  The  scientific  application  and  appre- 
ciation of  climate  as  such,  and  its  effects  on  disease,  belong  to  more 
modern  days  and  have  gone  hand  in  hand  with  the  study  of  meteorology. 
45 


682  CLIMATIC  THERAPEUTICS 

Eichard  Morton  (1637)  (Osier,  '04),  in  speaking  of  the  prevention 
of  tuberculosis,  advocated  "  open,  fresh,  kindly  air,  and  such  as  is  free 
from  the  smoke  of  coals." 

Benjamin  Eush,  in  1793,  writing  on  the  palliative  treatment,  says: 
"  The  first  remedy  under  this  head  is  a  dry  situation.  .  .  ,  The  higher 
and  drier  the  situation  which  is  chosen  for  this  purpose  the  better. 
.  .  ,  Much  has  been  said  in  favor  of  sea  voyages  in  consumption.  In 
the  mild  degrees  of  the  disease  they  certainly  have  done  service;  but 
I  suspect  the  relief  given  or  the  cures  performed  by  t^liem  should  be  con- 
fined chiefly  to  seafaring  people,  who  add  to  the  benefits  of  a  constant 
change  of  pure  air  a  share  of  the  invigorating  exercises  of  navigating 
the  ship." 

GENERAL    DEFINITION    OF    CLIMATOTHERAPY 

Climatotherapy  is  the  application  of  climatic  factors  in  the  treat- 
ment of  disease. 

Meteorologically  considered,  climate  may  be  said  to  depend  on  (1) 
distance  from  the  equator,  (2)  the  elevation  above  the  sea  level,  and 
(3)  the  distribution  of  the  land  and  water  over  the  surface  area.  The 
amount  of  sunshine,  heat,  and  humidity  will  be  dependent  on  the  above 
factors. 

In  all  diseases,  but  especially  in  tuberculosis,  many  other  factors, 
independent  of  atmospheric  conditions,  must  be  embraced  within  the 
term  climatic  treatment.  The  individuality  of  the  patient,  his  environ- 
ment, his  resources,  his  intellectuality,  his  mental  attitude,  and  the  stage 
of  the  disease  must  be  considered  before  a  change  of  climate  is  advised. 
Then,  too,  it  must  be  remembered  that  one  place  may  offer  ideal 
atmospheric  conditions  for  a  climatic  change,  while  it  gives  unfit 
or  no  accommodations,  with  poor  food  and  little  comfort.  All  these 
factors  not  dependent  on  meteorologic  conditions  are  included  in 
the  term  climatotherapy,  and  in  this  sense  the  subject  will  here  be 
treated. 

IS    THERE    A    SPECIFIC    CLIMATE    FOR    PULMONARY 
TUBERCULOSIS  ? 

No  climate  is  a  specific  for  this  disease.  In  choosing  a  climate, 
individualization  must  be  the  kej^note  of  treatment.  The  old  idea  of 
a  particular  zone  or  a  climate  conferring  immunity  to  tuberculosis  has 
been  generally  given  up.  There  is  still  reason  and  good  authority  to 
believe  that  tuberculosis  exists  less  in  dry  regions,  either  in  dry  forest 
places  or  in  elevated  and  low-lying  desert  lands.     Such  places  are  rela- 


IS  THERE  A  SPECIFIC  CLIMATE   FOR  TUBERCULOSIS?        683 

tively  free  from  tuberculosis  because  the  inhabitants  live  out  of  doors, 
in  the  pure  air,  in  localities  not  yet  contaminated  by  settled  districts. 
When  these  places  are  thickly  populated  and  cities  are  formed,  tuber- 
culosis is  no  longer  rare,  even  among  the  natives.  In  other  words,  it 
is  the  social  life  and  unhygienic  conditions  which  beget  the  spread  of 
tuberculosis  and  not  the  climate  that  prevents  it.  This  is  shown  in  the 
American  Indian,  when  taken  from  his  native  environment  and  placed 
in  settled  districts  or  under  changed  social  conditions.  The  increasing 
mortality  from  tuberculosis  of  the  American  negro  (Brandt,  '03)  since 
the  war  also  verifies  this  point.  Before  the  war  he  was  well  housed, 
cared  for,  living  an  agricultural  life.  Since  the  war  the  negroes  have 
drifted  into  the  cities,  living  under  most  unhygienic  conditions.  Havard 
('05),  Assistant  Surgeon  General,  U.  S.  A.,  writing  on  the  mortality  in 
tropical  climates,  shows  that  it  is  more  the  local  social  conditions  than 
any  factor  of  climate  that  is  responsible  for  the  great  prevalence  and 
mortality  of  tuberculosis  in  Manila  and  Havana. 

Treatment  of  tuberculosis  by  climate  requires  more  than  merely  the 
study  and  knowledge  of  the  meteorologic  conditions,  and  yet  in  no  other 
disease  does  climate  play  so  important  a  therapeutic  role.  Climato- 
therapy  is  the  close  study  of  individual  tastes  for  each  and  every 
patient,  and  in  fact  all  conditions  that  arise  in  relation  to  the  place 
selected — atmospheric,  topographic,  sociologic,  ps3^chic,  and  economic. 
Too  much  stress  has  been  laid  on  temperature,  humidity,  and  altitude 
to  the  exclusion  of  other  factors,  such  as  social  and  hygienic  conditions, 
proper  and  congenial  environment. 

More  and  more  are  we  studying  the  individual  requirements  of  cli- 
mates for  tuberculosis,  and  a  patient  should  never  be  advised  to  make 
a  change  without  a  knoAvledge  of  the  conditions  to  which  he  will  be 
subjected.  It  is  not  so  many  years  ago  when  it  seemed  necessary  to 
send  the  patients  to  a  climate  heralded  for  some  specific  quality,  and 
a  relaxing  climate,  like  Madeira,  was  the  favorite  choice.  Then  came 
the  inland  climates,  and  later  the  tonic  and  stimulating  effects  of  the 
high,  dry,  cold  air  of  the  Alps  and  Eockies;  and  more  recently,  still, 
has  come  the  realization  that  tuberculosis  can  be  treated  successfully 
in  any  locality.  Some  modern  therapists  deny  the  efficacy  of  any  cli- 
mate, one  holding  (Flick,  'OG)  "that  there  is  absolutely  nothing  in 
climate  in  tuberculosis."  The  difficulty  lies  in  the  fact  that  the  pendu- 
lum swings  too  far  whenever  anything  new  in  medicine  is  exploited,  so 
that  when  cures  are  made  in  the  moist  climates  there  are  those  who 
seem  to  lose  sight  of  how  much  more  might  be  done  with  the  added 
climatic  factors.  Fortunately,  the  pendulum  has  swung  back  to  a  more 
rational  position,  so  that  to-day,  with  our  individualization  of  treat- 
ment, every  factor,  climatic  or  nonclimatic,  is  utilized. 


684  CLIMATIC  THERAPEUTICS 

PRINCIPAL    TYPES    OF    CLIMATE 

The  classification  of  climates  has  always  been  a  difficult  matter  to 
all  climatologists.  A  method  based  on  geographical  position  (distance 
from  the  sea  and  distance  from  the  equator)  offers  less  complications 
than  one  dependent  on  physiologic  or  therapeutic  effects.  It  is  the 
purpose,  here,  to  arrange  the  types  in  the  manner  that  appeals  most  to 
the  writer — i.  e.,  distance  from  the  sea — giving  the  climatic  factors  com- 
mon to  the  various  types.  With  this  thought  in  mind,  the  following 
classification  is  presented  : 

f  A.  Sea  voyages. 
I.  Ocean.      J  B.  Island. 

Ic.  Coast. 


II,  Inland.  . 


'A.  Low  altitude   (up  to  1,000  feet). 

B.  Medium  altitude   (1,000  to  3,000  feet), 

C.  High  altitude  (3,000  to  6,500  feet). 

D.  Deserts. 


The  meteorologic  factors  of  these  different  typos  will  be  taken  account 
of  as  each  group  is  considered  in  turn.  The  chief  elements  that  give 
character  to  any  distinct  climate  are  temperature,  the  degree  of  mois- 
ture (for  practical  purposes  confined  to  relative  humidity),  the  wind 
conditions,  and  the  atmospheric  pressure.  Among  elements  of  minor 
import  might  be  named  the  electric  phenomena  of  the  atmosphere. 
Other  factors  that  have  influence  on  the  climate  of  small  areas  are  the 
character  of  the  soil,  whether  dry  or  moist,  distance  from  or  nearness 
to  bodies  of  water,  size  and  nature  of  forests,  vegetation,  density  of 
population.  Nonporous,  damp  soil  may  be  detrimental,  because  by  it 
the  humidity  of  the  air  in  such  a  region  may  be  changed  ;  too  dry  a  soil, 
if  there  is  much  wind  stirring,  may  not  be  beneficial  on  account  of  the 
dust  produced;  nearness  of  large  areas  of  water  changes  the  wind  con- 
ditions. Large  forests  give  protection  against  winds,  and  on  the  other 
hand,  when  coolness  is  needed,  prevent  the  breeze  from  reaching  the 
place.  They  are  often  a  protection  from  dust  and  pathogenic  organ- 
isms.    Much  vegetation  produces  humidit3^ 

I.  Ocean  Climates. — Here  temperature,  according  to  latitude,  varies 
less  than  with  inland  climates.  The  general  characteristics  and  im- 
portant properties  of  ocean  climates  ai-e  pure  air  and  freedom  from 
dust  and  pathogenic  organisms;  in  general,  they  are  moist  and  equable. 
The  evenness  of  the  temperature  is  characteristic;  the  difference  of  the 
temperature  between  day  and  night,  for  both  summer  and  winter,  is  less 
than  the  inland  climate,  and  in  southern  latitudes  the  temperature  is 


PRINCIPAL  TYPES  OF   CLIMATE  685 

equable  the  year  around,  modified  more  or  less  by  the  Gulf  Stream  aud 
other  strong  ocean  currents. 

The  physiologic  properties  of  the  ocean  climate,  according  to  Schroeder 
and  Blumenfeld  ('04)  show  that  the  heart  action  is  strengthened  and 
that  the  pulse  is  slowed,  for  the  moist  air  and  air  currents  cool  the  skin 
and  lead  to  the  contraction  of  the  blood-vessels.  This,  in  turn,  reflexly 
leads  to  increased  heart  action  and  dilatation  of  the  blood-vessels  of  the 
skin,  and  finally  to  a  cutaneous  hyperemia.  The  ocean  climates,  in  gen- 
eral, have  a  sedative  and  relaxing  effect  on  the  nervous  system.  The 
mucous  membrane  and  skin  are  more  active.  The  increased  pressure 
leads  to  increased  depth  and  slowing  of  respiration.  The  metabolism  is 
considerably  augmented,  and,  on  account  of  the  respiration,  more  carbon 
dioxid  is  thrown  out.  With  this  change  of  metabolism  comes  an  increase 
of  weight,  and  an  increase  of  blood  cells  and  hemoglobin. 

This  important  effect  on  metabolism  is  a  matter  of  individuality. 
Many  persons,  sick  or  well,  who  have  made  a  change  to  an  ocean  climate, 
with  whom  such  a  climate  agrees,  may  show  just  such  results,  while  oth- 
ers will  not  improve  at  all  in  the  same  climate.  Based  on  this  adapta- 
bility of  the  individual  to  particular  climates,  Pluggard  ('06),  in  dis- 
cussing types  of  climate,  states  that  "  the  tonic  or  relaxing  character  of 
a  climate  turns  chiefly  on  the  ability  of  the  organism  to  adapt  itself  to 
the  requirements.  Other  things  being  equal,  that  climate  is  most  tonic 
which  demands  the  greatest  amount  of  tissue  change  that  a  given  organ- 
ism can  permanently  yield."  He  shows  that  a  climate  that  is  tonic  and 
stimulating  to  one  person  may  be  relaxing  and  sedative  to  another,  and 
vice  versa. 

(a)  Sea  Voyages. — On  a  voyage  with  favorable  weather  conditions, 
one  may,  for  a  long  period,  experience  the  general  characteristics  of  the 
ocean  climate,  receiving  the  benefit  of  outdoor  life  in  the  purest  of  air. 
On  the  other  hand;  the  weather  conditions  may  be  unfavorable,  with  rain 
and  high  winds.  In  general,  this  type  of  climatic  treatment  is  only 
applicable  in  the  earliest  stages  of  tuberculosis,  when  there  are  no  con- 
stitutional symptoms,  or  for  arrested  cases.  In  both  instances  the  pa- 
tient should  be  proof  against  seasickness.  The  objections  to  ocean  trips 
are  that  a  sufficiently  long  voyage,  under  unfavorable  weather  conditions, 
may  cause  much  confinement,  and  this,  with  the  poor  food  too  often 
found  on  the  ships  that  go  to  semitropical  and  tropical  countries,  may 
cause  disastrous  effects.  When  a  sea  voyage  can  be  made  in  a  sanatorium 
ship,  types  of  which  have  been  constructed  on  the  Continent,  then  such 
a  sea  voyage  may  be  free  from  many  of  the  drawbacks  which  ordinarily 
are  a  part  of  these  voyages. 

(&)  Island  Climates. — The  climates  of  small  islands  possess  practi- 
cally the  same  characteristics  as  the  ocean  climate,  and  besides,  persons 


686  CLIMATIC  THERAPEUTICS 

can  be  made  more  comfortable  on  an  island  and  not  suffer  from  seasick- 
ness. The  smaller  islands  are  not  recommended  for  tuberculous  persons, 
because  of  the  disadvantage  of  poor  accommodations  and  poor  food,  and 
isolation  of  the  patient,  which  too  often  leads  to  nostalgia.  One  of  the 
advantages  of  living  on  an  island  or  on  the  coast  is  that  sea  bathing  is 
possible,  but  this  only  applies  to  patients  in  the  arrested  stages  of  the 
disease,  for  those  with  active  trouble  should  not  bathe  in  the  open  sea. 
Sea  bathing  may  be  stimulating  if  not  indulged  in  excessively.  The  first 
bath  should  be  short,  a  mere  dip  of  two  or  three  minutes;  longer  bathing 
may  cause  much  depression.  If  the  limit  of  endurance  has  been  ex- 
ceeded, it  will  be  marked  by  a  chilly  feeling,  vertigo,  or  nausea. 

The  larger  island,  with  mountainous  districts,  adds  much  to  the 
scenic  effects  and  beauty  by  presenting  an  elevated  region  in  close  prox- 
imity to  the  ocean,  but  the  climate  no  longer  partakes  of  the  island 
character,  but  resembles  more  the  ocean  type. 

(c)  Coast  Climates. — The  coast  region  gives  equable  moist  condi- 
tions, and  practically  offers  the  only  ocean  climate  for  selected,  indi- 
vidual cases  of  tuberculosis.  The  atmosphere,  most  of  the  time,  is  cool 
and  damp,  often  foggy,  especially  along  the  western  coast  of  the  United 
States  and  Xorth  Sea.  Cermany.  Places  with  coast  climate  have  the  ad- 
vantage of  being  accessible,  and  are  often  provided  with  suitable  resorts, 
in  wliich  it  is  agreeable  to  live  and  where  excellent  accommodations  may 
be  found,  with  occasionally  a  sanatorium  for  the  treatment  of  tuberculosis. 

Many  coast  climates  may  be  warm  and  moist  during  the  summer 
months,  depending  on  prevailing  Avinds — the  land  and  sea  breezes — 
which  make  the  climate  equaljle.  During  the  day  the  breeze  blows  from 
the  sea  to  the  land,  and  during  the  night  from  the  cool  land  to  the  sea. 
The  physiologic  properties  of  the  ocean  climates,  given  above,  apply  espe- 
cially to  this  ty2:>e.  The  cases  to  be  sent  to  such  places  should  be  indi- 
vidualized, just  as  for  all  other  climates.  The  indications  may  be  grouped 
as  follows: 

(1)  The  most  favorable  are  early  cases  of  tuberculosis  without  fever 
or  marked  constitutional  symptoms.  (2)  Incipient  eases  with  early  and 
slight  hemorrhages.  (3)  Chronic  fibroid  cases,  with  or  without  bron- 
chitis or  emphysema.  (4)  Old  people  with  phthisis  or  a  recurrent  at- 
tack. ( 5 )  All  cases  complicated  with  cardiac  or  renal  disease.  ( 6 )  Young 
children  with  pulmonary  or  bone  lesions.  (7)  Cases  with  marked  nervous 
symptoms. 

II.  Inland  Climates. — The  temperature  varies  generally,  according 
to  the  season,  the  distance  from  the  ocean,  and  the  proximity  to  the 
mountains,  as  well  as  the  distance  from  the  equator.  In  general,  the 
mean  temperature  decreases  with  the  distance  from  the  equator.  As 
the  altitude  increases  the  atmospheric  pressure  decreases,  the  humidity 


PKINCIPAL  TYPES   OF   CLIMATE  687 

lessens,  the  changes  of  temperature  between  day  and  night  increase,  and 
the  sun's  rays  become  more  intense. 

(a)  Low  Altitude. — Generally  speaking,  the  climate  in  a  low  alti- 
tude is  moist  and  cold  in  winter,  moist  and  hot  in  summer,  the  mean 
temperature  diminishing  with  the  distance  from  the  equator,  being  more 
equable  according  to  the  proximity  of  the  ocean  climate  and  drier  ac- 
cording to  the  relative  position  of  the  mountains. 

(h)  Medium,  AUitudc. — The  climate  here  is  warm,  moderately  moist 
in  summer,  cool  and  moderately  dry  in  winter.  In  places  where  the 
rainfall  occurs  only  in  winter  the  climate  is  warm  and  moderately  dry 
in  summer,  these  factors  being  modified  by  local  conditions  such  as 
forests,  winds,  soil,  and  vegetation. 

(c)  High  Altitude. — Here  purity  of  air  is  the  dominant  feature. 
The  temperature  is  cool  and  dry  in  summer,  especially  in  altitudes  over 
4.000  feet;  cold  and  dry  in  winter,  but  modified  by  local  conditions. 
The  climate  is  characterized  by  the  changes  incident  to  diminished  air 
pressure,  by  abundance  of  sunshine,  snow,  rain  in  showers,  and  electric 
storms  in  summer  time.  In  former  times  ozone  was  considered  an 
important  factor.  There  seems  now,  however,  no  scientific  evidence 
that  ozone  is  liberated  anywhere  in  such  quantities  as  to  be  of  special 
service. 

The  physiologic  effects  of  the  high  altitude  consist  of  an  increase 
in  the  respiratory  and  cardiac  functions  and  an  increase  in  the  appetite 
and  general  metabolism.  Muscular  power  and  the  secretions  of  the 
mucous  membranes  are  diminished.     The  nervous  system  is  stimulated. 

The  effect  on  the  blood  has  long  been  a  matter  of  dispute.  The 
blood-pressure  is  held  to  be  decreased  slightly  (Huggard,  '06).  The 
amount  of  hemoglobin  is  increased.  The  white  cells  do  not  increase. 
That  there  is  an  increase  in  the  number  of  red  blood  cells  is  acknowl- 
edged, but  the  question  at  issue  is.  How  much  is  apparent  and  how 
much  is  real  ?  The  theories  that  have  been  brought  forward  to  account 
for  this  increase  are  based  either  on  changes  in  the  peripheral  circulation 
(Campbell  and  Hoagland,  '02),  by  changes  in  the  density  of  the  blood 
(Grawitz,  '95),  by  error  in  instruments  used  (Brlinings,  '03),  and  by 
changes  due  to  the  improved  general  health,  either  from  a  ])rolonged 
life  of  the  red  cells  (Fick,  '95)  or  by  formation  of  new  blood  elements 
(Schaumann  and  Rosenquist,  '97).  There  is,  undoubtedly,  some  in- 
crease in  the  number  of  new  blood  elements  formed,  but  hardlv  as  great 
as  the  blood  counts  would  indicate.  It  is  an  interesting  fact  that  the 
increase  in  the  number  of  red  cells  is  most  marked  in  tlie  first  few 
days,  reaching  its  maximum  in  the  first  month,  and  then  the  number 
rapidly  diminishes  on  descending  to  lower  levels.  Woinzirl  ('03)  has 
shown  that  cold  is  an  important  factor  in  the  production  of  the  blood 


688  CLIMATIC  THERAPEUTICS 

changes  at  high  altitudes.  It  should  be  remembered  also  that  stimu- 
lating climates  other  than  those  of  altitude,  through  their  effects  on 
appetite  and  metabolism,  lead  to  an  increase  in  blood  formation  (Scliroc- 
der  and  Blumenfeld,  '04).^ 

The  stimulating  effects  of  altitudes  ma}^,  however,  be  dangerous  in 
that  the  demand  made  on  the  respiratory,  circulatory,  and  muscular 
apparatus  produce  a  definite  strain  on  the  system,  and  if  the  patient 
is  not  sufficiently  robust,  or  if  he  is  injudicious  in  exercising  before 
being  acclimated,  serious  results  may  follow.  In  the  selection  of  an 
altitude  for  cases  of  tuberculosis  local  conditions  are  as  important  as 
is  the  consideration  of  the  constitutional  symptoms. 

Indications  for  high  altitudes  are:  (1)  Incipient  cases,  with  or  with- 
out fever;  (2)  cases  beyond  the  incipient  stage,  with  infiltration  or 
beginning  destruction;  (3)  cases  with  early  hemoptyses  or  laryngeal 
cases;  (4)  cases  with  pleurisy  or  with  old  pleuritic  exudate.  x\ny  of 
the  above,  with  or  without  constitutional  symptoms,  are  suitable  for 
altitudes  varying  from  4,000  to  6,000  feet. 

The  contraindications  for  high  altitudes  are:  (1)  Too  great  an  in- 
volvement or  softening  in  both  hmgs ;  (2)  cavity  formations  with  much 
hemoptysis;  (3)  cases  complicated  with  kidney  or  heart  disease  or  dia- 
betes; (4)  cases  with  marked  emphysema  (asthmatics)  ;  (5)  the  very 
3'oung  tuberculous ;  ( 6 )  fibroid  cases,  with  dyspnea ;  ( 7 )  advanced  laryn- 
gitis;  (8)   excessively  nervous  patients. 

The  indications  and  contraindications  enumerated  al)ove  have  the 
support  of  many  authorities.  There  are  various  opinions  for  and  against 
sending  hemorrhagic  cases  to  altitudes  of  over  2,000  feet,  on  account 
of  the  greatly  diminished  air  pressure.  The  writer's  opinion  is  that 
hemorrhage,  of  itself,  is  not  a  contraindication,  except  that  in  advanced 
cases,  with  frequent  hemorrhages  and  cavity  formation,  with  a  history 
of  much  bleeding,  medium  and  high  elevations  are  not  indicated.  Camp- 
bell ('02)  states  that  altitude  does  not  apparently  increase  tlie  mortality 
of  hemorrhagic  cases,  but  in  his  series  of  250  patients  the  nonhemorrhagic 
cases  had  the  advantage  over  the  hemorrhagic  in  the  improvement. 

{d)  Desert  Climates. — To  this  type  belong  the  inland  climates  of 
low  and  medium  altitudes.  A  few  desert  places  of  value  in  the  United 
States  are  below  sea  level.  These  are  characterized  by  an  abundance 
of  sunshine,  purity  of  air,  low  humidity,  frequent  winds  and  dust 
storms.  The  disadvantages  of  this  type  are  the  unpleasant  winds,  at 
times  accompanied  by  much  dust  and  sand,  unsuitable  accommodations, 
poor  food,  which  often  lead  to  nostalgia  and  mental  depression. 


*  The  increase  of  lymphocytes  in  high  altitudes  as  well  as  their  effect  in  improv- 
ing patients,  noted  by  Webb  and  Williams  ('09)  should  also  be  noted  here. — Editor. 


PRINCIPAL  TYPES  OF   CLIMATE 


689 


The  indications:  for  desert  climates  are:  (1)  Patients  with  compli- 
cating bronchitis  and  emphysema,  especially  those  with  abundant  secre- 
tion; (2)  albuminuria  or  kidney  lesion.'^;  (3)  far  advanced  cases  and 
those  of  the  third  stage,  that  seem  unfit  for  any  other  climate,  may 
do  surprisingly  well. 

From  what  has  been  said  concerning  the  indications  and  contra- 
indications of  climatic  treatment,  the  results  of  such  treatment  are 
dependent  not  only  on  climatic  elements,  but  on  the  individuality  of 
patients.  Schroeder  and  Blumenfeld  (04)  summarize  their  view  (see 
Table  I,  below)  of  this  subject  as  follows:  "There  are  climatic  factors 
of  eminent  importance  in  the  treatment  of  tuberculosis.     We  can  find 


TABLE   I  > 

Comparison  of  Results  in  Tuberculous   Treatment.     (Summary) 


^■arikty  of 
Climatk 

Total 

Nwniber 

of 

Cases 

First 

Stage 

(Turban) 

Second         Positive 

and                  or 
Third        Favorable 
Stages     !     Results 

Negative 
or  Un- 
favorable 
Results 

Names  of  Resorts 

(iROUP     A. 

Sea  Climate 

and 
Coast  Climate 

3455 

835 

24.7% 

2620 
75.3% 

2515 

72.8% 

Madeira, 
Arcachon, 
West  Riviera, 

940          Entire  Riviera, 
Norderney, 
Danish  Coast, 

27.2%    Norwegian  Coast, 
Sea  Voyages. 

Group  B. 

Interior  Land 

Climate 

3322 

1221 
36.7% 

2101 
63.3% 

2815 

88% 

507 

12% 

Grabowsee, 
Bedfort,  Belzig, 
Lohr,  Altena, 
Engelthal, 
Ruppertshain. 

Group  C. 
Altitude 

3257 

.... 

1222 

37.5% 

2035 
62.5% 

2856 

87.7% 

401 

12.3% 

Schoemberg, 

Climate  up  to  3,000 
feet 

Friedrichsheim, 

Goerbersdorf, 

Albertsburg. 

Group  D. 

Altitude 

Climate  abo\  e 
3,000  feet 

2271 

.... 

953 
41.5% 

1318 
58.5% 

1898 
83.8% 

373 
16.2% 

Neu-Schmecks, 
Davos,  Zurich, 
Asheville. 

'  These  stati.stics  are  from  Schroeder  and  Blumenfeld  ('04)  and  show  the  results 
of  treatment  in  sea  and  land  climates  of  different  kinds.  In  considering  these 
figures,  the  difficulties  encountered  in  making  comparisons  between  patients  in 
different  stages  must  be  kept  in  mind. 


690  CLIMATIC  THERAPEUTICS 

them  on  the  seacoast,  in  the  interior,  in  various  levels  ahove  the  sea. 
But  there  is  no  specific  climate  for  phthisis.  Only  elements  which 
assist  our  therapeutic  endeavors  are  to  be  found  in  every  climate  of 
the  moderate  zone.  In  sea  and  altitude  resorts  they  may  act  too  power- 
fully and  become  harmful.  The  strictest  individualization  is  therefore 
necessary  when  they  are  recommended.  It  ought  to  become  the  common 
property  of  all  physicians  that  nothing  can  become  more  harmful  to 
tuberculous  patients  than  the  routine  belief  in  a  specific  influence  on 
tuberculous  processes  through  climate." 

GENERAL    UTILIZATION    OF    CLIMATIC    TREATMENT 

From  what  has  been  previously  written  in  this  chapter,  it  is  evident 
that  in  choosing  a  health  resort,  the  nonclimatic  factors  as  well  as  the 
meteorologic  elements  must  be  considered.  As  there  is  no  climate  spe- 
cially suited  for  all  tuberculous  patients,  no  simple  rule  as  to  the  best 
climate  can  be  followed  strictly.  Patients  who  do  not  react  to  the  extra 
demands  of  a  cold  climate  will  do  better  in  a  semitropical  region.  For 
instance,  young,  robust  indi\iduals  with  tuberculosis,  sent  to  a  cold, 
dry  mountain  resort,  Avill  find  living  in  the  open  air  easier,  and  will  have 
better  appetite  and  digestion,  and  Avill  improve  more  than  the  weak 
and  old  with  a  similar  type  of  disease,  these  latter  improving  more  in 
a  mild,  warm  climate  of  lowered  elevation. 

In  choosing  a  resort,  the  factors  to  be  considered  are: 

1.  Atmospheric  conditions. 

2.  General  topography. 

3.  Social  environment. 

4.  Economic  circumstances  of  the  patient. 

5.  Psychic  condition  of  the  patient. 

1.  The  elements  of  atmosphere  in  their  relative  importance  are: 
(1)  Purity  of  air;  (2)  percentage  of  sunshine;  (3)  pressure  of  air; 
(4)  the  amount  of  humidity;  (5)  the  temperature  and  its  variations, 
diurnal  and  otherwise;  (6)  the  winds,  their  severity  and  whether  laden 
with  dust  or  other  impurities. 

2.  In  regard  to  the  topography,  the  place  (1)  should  have  a  dry, 
porous  soil;  (2)  should  be  protected  from  strong  winds  by  hills  or 
forests;  (3)  should  be  free  from  dust;  (4)  have  sufficient  open  grounds, 
and  (5)  a  view  and  vegetation  pleasing  to  the  eye. 

3.  Under  social  environment  are  to  be  considered  (1)  the  size  and 
density  of  the  population;  (2)  the  general  sanitation;  (3)  the  restric- 
tions and  health  rules  governing  invalids;  (4)  the  number  and  extent 
of  industrial  activities,  all  of  which  may  be  factors  in  the  making  or 
marring  of  the  climate  of  a  resort. 


GENERAL   UTILIZATION   OF   CLIMATIC  TREATMENT  691 

4.  The  economic  factor  is  a  most  important  one,  for  the  cost  of 
living  is  everywhere  increasing,  and  what  were  once  considered  luxuries 
are  now  placed  among  the  comforts  of  life.  Has  the  resort  to  which  the 
patient  is  to  be  sent  good  accommodations?  Suitable  and  hygienic 
houses  and  homes,  w^here  the  proper  food  can  be  obtained,  are  also 
necessary,  and  for  many  patients  light  amusements  and  pleasurable 
diversions  are  additional  factors.  It  must  be  known  that  good  medical 
attendance  can  be  had  at  all  times.  To  obtain  these  ends  the  patient 
should  be  in  command  of  sufficient  money  to  give  him  the  necessary 
comforts  for  at  least  one  year. 

5.  The  psychic  element  is  by  no  means  to  be  underestimated.  The 
patient  should  strongly  desire  the  life  of  the  particular  resort  chosen, 
and  be  mentally  in  harmony  with  what  such  a  climate  offers.  An 
element  may  act  as  a  psychic  depressant  to  one  patient  and  have  the 
opposite  or  no  eifect  on  another.  It  is  easily  comprehensible  that  con- 
tinued cloudiness  and  fog  is  depressing,  but  a  stronger  psychic  force 
is  working  when,  as  happens,  patients  find  a  cloudless  climate  and 
abundant  sunshine  monotonous  and  irritating.  It  is  unwise  to  send 
patients  to  places  where  the  surroundings  produce  depression.  The 
psychic  element  in  many  cases  is  so  strong  a  factor  that  it  must  be 
recognized  and  successfully  met.  The  physician  who  individualizes  most 
carefully  will  have  the  best  results.  He  will  not  send  a  patient  who 
has  been  used  to  comforts  and  luxuries  to  a  climate  meteorologically 
ideal  where  the  surroundings  are  uncongenial,  the  accommodations  mea- 
ger, and  the  food  poor;  nor  will  he  send  an  active,  easily  tempted  tem- 
perament to  an  ideal  resort  where  any  phase  of  fast  living  is  easily 
obtained. 

H.  P.  Loomis  ('06)  has  aptly  put  it  tlnis:  "Each  case  is  to  be 
studied,  not  as  one  having  a  certain  disease  which  is  ordinarily  benefited 
by  such  and  such  a  climate,  but  as  an  individual  with  distinct  tem- 
perament, inclinations,  and  personal,  peculiar  phases  of  the  disease." 

Bullock  ('02),  in  speaking  on  the  same  subject,  writes:  "  So  impor- 
tant do  I  consider  the  psychic  status  in  any  given  case,  that  if  a  patient 
persists  in  a  pessimistic  viewpoint,  occasion  is  taken  to  have  a  talk,  the 
purport  of  which  is  that  '  it  might  be  better  to  go  somewhere  else ' ;  for, 
without  the  cooperation  of  our  patients,  '  in  spirit  and  in  truth,'  there 
is  so  little  to  be  gained  that  the  game  is  hardly  worth  the  candle.  .  .  . 
The  psychic  element  in  the  treatment  of  the  tuberculous  is  well  illus- 
trated by  conditions  at  the  government  sanatorium  at  Fort  Bayard. 
Patients  are  ordered  there  for  treatment ;  the  opportunity  to  get  well 
is  not  sought,  it  is  thrust  on  them.  The  regime  at  Fort  Bayard,  from 
a  scientific  viewpoint,  is  above  criticism;  nevertheless,  because  the  pa- 
tients belong  to  a  class  who  do  not  appreciate  anything  forced  on  them. 


692  CLIMATIC  THERAPEUTICS 

no  matter  how  good,  the  psychic  state  opposing  rather  than  favoring 
recovery,  the  results  will  never  be  comparable  to  those  obtained  in  an 
institution  where  the  opposite  state  of  mind  prevails.  In  spite  of  this 
great  disadvantage,  the  patients  who  have  really  appreciated  the  oppor- 
tunity to  get  well  have  been  sufficiently  numerous  to  demonstrate  beyond 
cavil  the  superlative  advantage  of  a  favorable  climatic  environment  in 
the  application  of  the  principle  of  modern  phthisio-tberapeutics." 

OPEN    AND    CLOSED    RESORTS 

For  so  long  a  time  has  climate  been  looked  on  as  a  factor  in  the 
treatment  of  tuberculosis  that,  according  to  the  mode  of  life  followed 
by  the  patient,  the  terms  open  and  closed  treatment  have  come  into 
use.  The  closed  resorts  are  those  where  patients  avail  themselves  of 
the  climatic  treatment  in  institutions  or  sanatoria,  and  the  open  resorts 
those  in  which  patients  pursue  the  treatment  outside  of  institutions — 
in  homes  or  hotels  or  wherever  they  choose. 

That  the  sanatorium,  combined  with  climatic  treatment,  gives  the 
best  results  for  all  early  active  cases  is  beyond  question.  Of  the  factors 
which  help  toward  the  good  results  of  this  combined  climatic-sanatorium 
treatment,  there  is  no  doubt  that  the  sanatorium  methods — that  is,  the 
attention  to  diet,  exercise,  hydriatic  measures,  and  regulated  mode  of 
life  in  the  open  air — have  more  to  do  with  the  good  results  obtained 
than  anything  in  the  climate  itself. 

In  the  early  days  of  the  sanatorium  doctrine  it  was  claimed  that  the 
tuberculous  must  be  treated  in  such  an  institution,  situated  in  some 
special  climate.  Later,  as  the  results  of  sanatorium  treatment  in  all 
kinds  of  climate  became  known,  this  view  was  modified,  and  it  was 
claimed  that  all  consumptives  were  to  be  treated  in  institutions,  because 
proper  modes  of  living  were  almost  impossible  in  an  open  resort.  This 
extreme  view  is  to-day  somewhat  modified,  for  we  have  come  to  a  more 
rational  view  in  realizing  that  there  can  be  no  rule  or  dogma  for  all 
cases.  We  know  now  that  some  do  better  in  the  home,  under  suitable 
regime,  and  that  others  improve  more  in  sanatoria,  irrespective  of  cli- 
matic advantages  or  disadvantages. 

It  is  to  be  remembered,  however,  that  the  attainment  of  the  hygienic- 
dietetic  and  other  needs  enumerated  are  dependent  not  solely  on  the 
possession  of  well-constructed  buildings  in  suitable  places,  but  more  on 
the  guiding  hand  of  the  institution — namely,  the  medical  director.  The 
results  will  be  largely  dependent  on  him,  while  the  grouping  of  buildings 
and  patients  enables  him  to  carry  out  the  work  more  easily. 

Babcack  ('07)  says  that  without  good  accommodations  and  the 
attendance   of   skilled   phthisio-therapists,   the  home   climate,   with    all 


OPEN  AND  CLOSED  RESORTS  693 

its  drawbacks  of  weather,  is  preferable,  and  again  that  the  average 
physician  is  not  sufficiently  informed  concerning  the  best  methods  of 
utilizing  the  home  climate,  or  he  will  not  take  the  trouble  to  so  im- 
press and  instruct  his  patients  that  good  results  in  the  home  may  be 
rendered  possible. 

A  change  of  scene  is  nearly  always  desirable  for  every  consumptive, 
and  such  a  beneficial  change  may  be  made  by  moving  the  patient  to 
the  top  floor,  to  the  roof,  or  by  utilizing  a  porch,  or  by  moving  him 
from  city  surroundings  to  the  suburbs  or  country.  Such  changes  are 
all  that  can  be  had,  for  the  present,  by  the  great  mass  of  tuberculous 
people,  the  majority  of  whom  are  poor,  and  who  must  have  the  best 
treatment  at  the  least  possible  expense. 

There  is  no  rule  for  the  rich.  Cases  must  1)6  individualized  and 
treated  according  to  the  individual  characteristics  and  requirements  of 
the  patients.  For  instance,  given  a  group  of  rich  patients,  with  each 
member  of  the  group  in  approximately  the  same  stage  of  the  disease, 
some  should  be  treated  at  home  and  others  sent  to  a  resort. 

"With  our  increased  knowledge  of  the  results  of  home  treatment, 
some  will  do  better  in  the  home  or  in  near-b}^  sanatoria  than  in  far- 
distant  institutions,  for  the  following  reasons :  At  or  near  home  such 
patients  may  be  made  more  comfortable,  have  adequate  accommodations, 
better  food,  be  happier  through  nearness  of  family  and  friends,  and 
be  less  depressed  than  if  in  the  presence  of  sick  people.  The  disad- 
vantages of  home  treatment  are  that  it  is  often  difficult  to  control  the 
patients  and  keep  them  to  regular  habits,  and  prevent  the  worry  con- 
sequent on  domestic  and  business  cares.  Frequently,  too,  the  family 
becomes  an  obstacle  to  the  desired  ends  through  lack  of  cooperation  with 
the  physician. 

In  general,  when  patients  have  insufficient  means  to  meet  the  extra 
demands  of  removal  and  the  proper  life  in  a  suitable  climate,  it  is  best 
to  have  them  remain  at  home,  no  matter  what  the  local  climatic  condi- 
tions may  be. 

In  sending  a  patient  to  a  resort,  the  question  naturally  arises.  Where 
shall  he  live?  The  large  hotels  are  to  be  avoided,  since  they  offer  too 
great  temptations  for  irregidar  habits  and  are  less  adapted  for  the  out- 
door life.  Many  of  the  large  hotels  also  state  that  they  do  not  receive 
tuberculous  patients.  What  is  meant,  however,  is  that  they  do  not 
accept,  as  guests,  persons  who  are  in  the  open  stage  of  the  disease.  There 
is  usually  no  objection  to  persons  who  have  had  tuberculosis  and  who 
have  no  bacilli-laden  expectoration  or  show  signs  of  active  trouble.  All 
these  things  considered,  with  our  present  knowledge  of  the  correct  regime 
for  the  tuberculous,  it  would  seem  best  that  the  patient  rent  a  house 
or  go  to  a  good  boarding  place,  remaining  under  the  constant  super- 


694 


CLIMATIC  THERAPEUTICS 


vision  of  a  competent  physician.  Or  when  the  health  resort  hoasts  of 
a  sanatorium,  the  patient  may  enter  such  an  institution.  Whether  a 
patient  is  to  have  institutional  or  noninstitutional  treatment  depends 
on  the  individual  case,  except  that  a  patient  who  is  always  bright, 
cheerful,  and  sanguine  is  likely  to  do  well  in  either  location.  The 
advantages  to  those  who  go  to  the  sanatoria  are  that  more  often  the 
patients  there  make  a  business  of  the  treatment.  It  is  easier  to  keep 
habits  and  rules  because  others  are  doing  the  same.  The  mental  train- 
ing, in  the  way  of  hope  and  encouragement,  given  to  patients  is 
also  productive  of  great  beneficial  effects.  The  disadvantages  of  sana- 
torium life  to  not  a  few  are  the  homesickness,  the  monotony  of  the 
food  and  care,  and  the  depression  caused  by  the  presence  of  other  sick 
people. 

The  advantages  to  many  who  live  in  the  open  resorts  are:  Freedom, 
through  daily  change  of  routine,  Avhich  is  always  stimulating;  the  grati- 
fication of  mental  and  physical  tastes,  and  the  greater  variety  of  amuse- 
ments and  entertainments  in  their  hours  of  exercise  and  rest  (which, 
however,  may  work  for  good  or  harm),  and  the  individual  choice  of 
medical  attendants. 

It  will  be  understood  from  the  foregoing  that  the  decision  as  to 
the  relative  value  of  open  and  closed  resorts  is  no  easy  one,  since  so 
many  factors  other  than  the  purely  climatic  ones  must  be  taken  into 
consideration.  Here,  as  elsewhere,  statistics  give  only  a  limited  view- 
point of  the  relative  value. 

Table  I  (page  689)  gives  the  results  of  treatment  obtained  in  dif- 
ferent types  of  climatic  resorts  drawn  from  various  sources,  all  but 
about  one  third  of  the  patients  belonging  to  the  coast  group,  having 
been  treated  in  closed  institutions. 

TABLE   II 

Results  of  Treatment  in  Insurance  Sanatoria  of  Germany 


Public  i\  Closed 

S.\NATOKI.\ 

Favorable 
Results 
Able  to 

Return  to 
W(<rk 

Unfavorable 
Results 

Total 
Treated 

Percentage 
of  Good 
Results 

Percentage 
of  Un- 
favorable 
Results 

Tuberculous  patients  treated 
in — 

1898 

1899         

3,623 

5.696 

8.037 

11.249 

12,885 

1.287 
2,002 
3,057 
3,407 
3,604 

4,910 

7,698 

11,094 

14,656 

16,489 

73  8% 

74% 

72.3%, 

76.8%, 

77.6% 

26.2% 

26%, 

1900 

1901 

1902 

27.7% 
23.2% 
22.4% 

Total 

41,490 

13,357 

54,,847 

74.9% 

25.1% 

OPEN  AND   CLOSED   RESORTS 


695 


Table  II  presents  the  results  of  treatment  obtained  by  the  Insurance 
Sanatoria  of  Germany  (Keport  "05),  many  of  which  institutions,  for 
obvious  reasons,  are  not  located  in  the  most  favorable  climatic  envi- 
ronments. 

Eecently,  Cornet  ('07)  has  come  forward  and  cited  his  own  experi- 
ence and  that  of  other  authorities  (Koeniger,  Hin-sch)  to  show  that 
the  results  are  as  good  in  the  open  as  in  the  closed  resorts,  but  his 
statements  have  already  been  questioned  (Roepke,  '07;  Kraus,  '07). 
Eoepke,  for  instance,  makes  a  careful  analysis  of  the  figures  quoted  by 
Cornet  from  Hinsch  concerning  the  results  of  treatment  at  the  open 
resort  at  the  Lippspringe  Bath,  in  the  principality  of  Lippspringe, 
Germany,  and  after  inquiry  into  some  974  cases  treated  in  the  open 
Lippspringe  Bath  resort,  quoted  by  Hinsch,  Eoepke  compares  these  with 
a  series  of  2.131  tuberculous  patients  treated  at  the  Auguste  Viktoria 
Stift  Sanatorium,  of  the  same  place. 

A  summary  of  Eoejjke's  results  may  be  seen  in  the  following  figures : 

TABLE  III 


Number  treated  at  open  Lippspringe 
Resort 

Number  treated  at  Auguste  yiktoria 
St  if  I  Sanatorium  at  Lippspringe.  .  . 


Stage  I 


859(88.2%) 
631(29.6%o) 


Stage  II 


Stage  III 


99(10.2%)    I      16(1.6%) 
938(44.0%)   I  562(26.4%) 


RESULTS 


Resulxs  of  Treat.mext 

AT  Open  Lippspringe 

Resort 

Stage  I                   Stage  II         ;        Stage  III 

Total 

Complete  recovery  .  .  . 

Partial  recovery 

Negative 

376(43.8%)  ,     21(21.2%) 

478(55.6%>)   :     75(75.8%) 

5(  0.6%)          3(  3.0%o) 

0  (0%) 
12  (75%) 
4(  2.5%) 

397(40.8%) 

.^,65(58.0%) 

12  (   1.2%) 

Results  of  Treatment 

AT  Augusle  Viktoria 

Slift   Sanatorium 

437(69.2%) 

181(28.7%) 

13  (  2.1%) 

4.30(45.9%) 

428(45.6%) 

80  (  8.5%) 

29  (  5.1%) 
299(53.3%) 
234(41.6%) 

Complete  recovery. . . 

Partial  recovery 

Negative 

896(42.0%) 
908(42.6%) 
327(15.4%) 

As  regards  the  interjiretation  of  the  above  figures,  to  use  Eoepke's 
own  Avords,  "  that  is,  the  number  of  first-stage  patients  treated  at  the 
Lippspringe  Bath  (open  resort)  are  three  times  as  great  as  at  the 
Sanatorium    (closed    resort).      The   number   of    second-stage    patients 


696  CLIMATIC  THERAPEUTICS 

treated  at  the  Lippspringe  Bath  is  four  and  a  half  times  less  than  those 
treated  in  the  Auguste  Viktoria  Stift  Sanatorium ;  and  yet,  in  spite  of 
the  much  worse  material  at  the  sanatorium,  the  results  of  treatment 
were  much  better  than  at  the  bath." 

Concerning  the  criticism  of  the  German  sanatoria  by  Cornet,  the 
opinion  seems  to  be  that  he  has  somewhat  overdrawn  the  picture.  It 
is  true  that  these  institutions  have  cost  an  enormous  amount  of  money 
and  the  permanent  results  obtained  have  been  less  than  has  been  desired, 
but  the  great  educational  value  of  such  institutions  and  the  real  benefit 
derived  by  hundreds  of  the  patients  treated  should  stand  as  sufficient 
reward  for  the  efforts  expended. 

THE  SELECTION  OF  A  SPECIAL  CLIMATE  OR  RESORT 

From  what  was  said  in  the  section  dealing  with  tlie  general  utiliza- 
tion of  climate,  it  will  be  understood  that  not  only  are  the  meteorologic 
conditions  to  be  considered  in  the  selection  of  a  health  resort,  but  the 
social  conditions  also.  Patients  with  limited  means  are  not  apt  to  do 
as  well  in  distant  resorts  as  those  who  can  purchase  the  comforts  needed. 
It  must  be  remembered  that  the  climatic  advantages  of  particular  re- 
sorts are  apt  to  ])e  magnified  l)y  those  who  are  interested  in  their 
success.  On  the  other  hand,  the  patient  must  be  told  that  every  cli- 
mate has,  at  times,  some  unpleasant  weather.  Here,  as  in  many  other 
things,  experience  is  often  the  best  teacher.  To  know  a  climate  and 
its  therapeutic  advantages,  the  meteorologic  and  social  conditions 
must  be  studied,  and  this  often  cannot  be  done  in  less  than  several 
months. 

Speaking  generally,  the  high,  dry  climate,  with  freedom  from  wind 
storms,  where  snow  and  rain  come  in  showers,  and  which  possesses  the 
greatest  possible  amount  of  sunshine,  is  recognized  as  the  best  place  for 
uncomplicated  cases  of  pulmonary  tuberculosis.  It  is  unfortunate  that 
such  climates  are  not  more  equable  than  they  are,  but  equability  is  a 
factor  usually  found  associated  with  moist  climates. 

The  indications  and  contraindications  for  different  types  and  degrees 
of  pulmonary  tuberculosis,  which  were  presented  in  the  section  dealing 
witli  types  of  climates,  suggest  to  what  extent  the  physical  condition 
of  a  patient  may  influence  the  selection  of  a  special  resort. 

In  addition  to  possessing  the  advantages  due  to  changed  meteoro- 
logic conditions,  a  proper  resort  should  have  suitable  accommodations 
for  leading  the  out-door  life,  and  should  have  good  food  and  pleasant 
surroundings.  Under  such  conditions,  with  freedom  from  business  and 
home  cares,  and  with  the  mental  and  physical  stimulation  from  the 
changed  surroundings  which  the  patient  is  given,  there  should  then  be. 


THE   SELECTION   OF   A   SPECIAL   CLIMATE   OR   RESORT        697 

with  proper  medical  supervision,  a  fair  chance  for  improvement.  If 
the  patient  pursues  the  climatic  treatment  in  an  institution,  he  learns, 
in  addition,  while  caring  for  himself  and  watching  others,  what  is  the 
best  mode  of  life  to  follow. 

Some  of  the  disadvantages  of  going  to  a  distant  resort  are  the  great 
expense  involved,  the  long  journey,  the  temptations  created  by  too  great 
an  amount  of  amusement  or  exercise,  and  the  fact  that  often  the  place 
chosen  is  not  the  one  most  needed  by  the  patient.  This  last  fault, 
however,  may  often  be  laid  at  the  door  of  the  physicians  who,  owing 
to  their  own  lack  of  knowledge  of  the  subject,  give  their  patients  most 
indefinite  directions  as  to  where  to  go.  Another  disadvantage  is  that 
the  patient,  after  undergoing  a  course  of  treatment,  finds  he  cannot 
return  to  his  former  home  because  of  the  great  difference  in  climatic 
factors. 

With  regulated  methods,  the  good  results  of  treatment  of  incipient 
cases  at  a  suitable  climatic  resort  should  be  at  least  ten  per  cent  higher 
than  in  closed  sanatoria  in  the  damp,  changeable  climate  of  the  East, 
Gardiner  ('01)   placing  the  figure  at  fifteen  per  cent. 

Henry  ('06),  in  discussing  types  of  climate  from  the  standpoint  of 
temperature,  gives  the  following  grouping: 

"  Classifying  as  warm  those  regions  having  an  annual  mean  tempera- 
ture of  G0°  [F.]  and  above,  it  will  be  found  that  such  regions  embrace 
the  southern  portion  of  North  Carolina,  South  Carolina,  Georgia,  Flor- 
ida, the  Gulf  States,  the  southwestern  portion  of  New  Mexico,  southern 
Arizona,  and  the  greater  part  of  California,  excepting,  of  course,  the 
mountain  districts. 

"  Classifying  as  temperate  those  regions  having  an  annual  mean  tem- 
perature between  50°  and  60°  [F.],  it  Avill  be  found  that  such  regions 
embrace  the  greater  portion  of  the  Middle  Atlantic  States,  the  Ohio 
Valley,  Tennessee,  the  southern  portions  of  Indiana  and  Illinois,  all  of 
Missouri,  Kansas,  Oklahoma,  and  .southeastern  Colorado. 

"  Classifying  as  cold  those  regions  having  an  annual  mean  tempera- 
ture of  40°  to  50°  [F.],  it  will  be  found  that  such  regions  embrace  the 
northern  tier  of  States,  including  the  northern  portion  of  Indiana, 
Illinois,  all  of  Iowa,  Nebraska,  South  Dakota,  "Wyoming,  and  the  moun- 
tain districts  of  the  West." 

The  classifications  of  resorts  according  to  distinguishing  meteorologic 
factors  are  always  imperfect  and  unsatisfactory,  but  in  keeping  with 
the  usual  vogue  such  a  grouping  is  here  presented : 

Cool  and  moderately  moist:  Canada,  Adirondacks,  Catskills. 

Cool  and  dry:  Colorado;  higher  altitudes  of  New  Mexico,  and  a 
few  in  Arizona;  high  altitudes  of  the  Alps,  Engadine  (Davos,  St. 
Moritz). 


698 


CLIMATIC  THERAPEUTICS 


Cool  and  moist:  Coast  of  Maine;  much  of  Canada;  mountains  of 
North  and  South  Carolina  and  West  Virginia. 

Warm  and  dry:  Medium  and  low  altitudes  of  New  Mexico  and 
Arizona  and  western  Texas;  southeastern  part  of  California;  Mojave 
Desert;  upper  and  lower  Egypt,  and  mountains  of  South  Africa. 

Warm  and  moist:  Florida,  Bermuda,  Madeira,  Canary  Islands,  South 
Africa,  and  Southern  California. 

Warm  and  moderately  moist:  Most  of  South  Carolina;  Georgia;  in- 
land of  Southern  California;  Kiviera;  southern  Spain;  north  coast  of 
Africa. 

Warm  and  moderately  dry:  High  elevated  regions  of  Southern  Cali- 
fornia, except  southeastern  part;  northern  and  central  Italy, 

ENUMERATION    OF    RESORTS 

The  space  allotted  to  this  sul)ject  does  not  allow  the  presentation 
of  the  advantages  and  disadvantages  of  the  large  number  of  places  in 
our  own  country  and  abroad  which  have  become  noted  as  resorts 
favorable  for  the  treatment  of  pulmonary  tuberculosis.  The  extent 
of    the   United    States  is   so   vast   and   the   formation   so   great,   with 

TABLE   IV 


Cities 


Boston,  Mass 

New  York,-  N.  Y. . .  . 
Philadelphia,  Pa. . . . 

Charleston,  S.  C 

Atlanta,  Ga 

Pensacola,  Fla 

New  Orleans.  La. . .  . 

Galveston,  Tex 

St.  Paul,  Minn 

Detroit,  Mich 

St.  Louis,  Mo 

Cincinnati,  Ohio. . .  . 

Memphis,  Tenn 

Cheyenne,  Wyo 

Denver,  Colo 

Salt  Lake  City,  Utah 

Portland,  Ore 

San  Francisco,  Cal . . 

San  Diego,  Cal 

Santa  Fe,N.  M 

Yuma,  Ariz 


15 

37 

42 

11 

1,052 

12 

8 

6 

758 

593 

466 

553 

268 

6,056 

5,219 

4,293 

20 

28 

40 

6,180 

137 


.a 

H 
t 

>< 

M 

EAN 

Monthly  Temperature 

a 

"-5 

>> 

93 

3 

j3 
05 

< 

05 

a; 

c 

3 
►-5 

>-5 

3 
3 
< 

u 

% 

Hi 

a 

Oi 

m 

a 

0 

O 

o 
Z 

S 

31 

27 

28 

35 

45 

57 

66 

72 

70 

63 

53 

42 

32 

33 

30 

31 

38 

48 

60 

69 

74 

73 

66 

56 

44 

34 

31 

32 

34 

40 

51 

62 

72 

76 

74 

68 

57 

45 

36 

33 

50 

52 

58 

65 

73 

79 

82 

81 

76 

67 

58 

51 

25 

46 

46 

52 

61 

70 

76 

78 

77 

72 

62 

52 

44 

24 

52 

56 

60 

67 

74 

80 

81 

82 

78 

70 

60 

54 

33 

54 

57 

63 

69 

75 

81 

83 

82 

79 

70 

61 

55 

33 

53 

56 

62 

69 

76 

82 

84 

83 

79 

72 

63 

57 

31 

12 

16 

29 

48 

60 

67 

74 

72 

62 

50 

32 

20 

33 

24 

25 

33 

46 

58 

67 

72 

70 

63 

52 

38 

29 

31 

32 

34 

44 

57 

66 

76 

80 

78 

70 

59 

44 

36 

32 

32 

35 

43 

54 

65 

74 

78 

76 

69 

57 

44 

36 

33 

41 

44 

52 

62 

71 

78 

81 

80 

73 

63 

51 

43 

33 

25 

26 

32 

41 

52 

61 

67 

66 

57 

46 

35 

29 

31 

29 

32 

39 

48 

57 

67 

72 

71 

63 

51 

39 

33 

30 

28 

33 

42 

50 

58 

67 

76 

75 

64 

52 

40 

33 

32 

39 

42 

47 

51 

57 

62 

67 

66 

61 

54 

46 

42 

32 

50 

52 

54 

55 

57 

59 

59 

59 

61 

60 

56 

51 

32 

54 

55 

56 

60 

62 

65 

68 

70 

66 

64 

59 

56 

30 

29 

32 

40 

47 

56 

66 

69 

68 

61 

51 

39 

31 

28 

54 

59 

64 

70 

77 

85 

92 

91 

84 

73 

62 

56 

C  05 

03  a 


49 
52 
54 
66 
61 
68 
69 
70 
45 
48 
56 
55 
62 
45 
50 
52 
53 
56 
61 
49 
72 


ENUMERATION   OF   RESORTS 


699 


moimtains,  inland  seas,  deserts,  various  latitudes,  and  the  two  oceans, 
that  any  type  of  climate  may  be  found.  For  a  complete  knowl- 
edge of  the  subject  the  reader  is  referred  to  the  larger  works  on 
climatology.^ 

To  show  how  widely  meteorologic  factors  differ,  the  monthly  and 
annual  temperature  means  of  cities  in  different  sections  of  the  country 
(Henry,  '06)  is  herewith  presented  (Table  IV). 

These  temperature  means  are  the  averages  of  observations  taken  by 
the  United  States  Weather  Bureau  (Henry,  '06)  over  periods  of  thirty 
years  or  more,  and  give  somewhat  of  an  idea  of  the  temperature  con- 
ditions met  with  in  different  parts  of  the  country.  Figure  175,  showing 
the  isotherms  or  lines  of  equal  average  temperatures  for  the  year,  pre- 
sents similar  knowledge  in  somewhat  different  form: 


Fig.  175  — Normal  Surface  Temperature  for  the  Year  in  the  United 

States. 

The  following  table  (Fig.  176)  shows  the  amount  of  rainfall  by  inches 
for  tlie  four  seasons  of  the  3'ear  for  twelve  different  cities  in  the  country, 
and  enables  one  to  note  at  a  glance  the  difference  in  rainfall  ])recii)itation 
for  these  various  regions  (Henry,  '06). 


•A  very  useful  book  in  this  connection  is  the  "Directorj'  of  Institutions  and 
Societies  Dealing  with  Tuberculosis  in  the  Ignited  States  and  Canada,"  published  by 
the  National  Association  for  the  Study  and  Prevention  of  Pulmonary  Tuberculosis, 
and  which  contains  a  list,  by  States,  of  the  sanatoria  in  the  United  States  and  Canada, 
and  the  capacity  and  charges  of  each. 


700 


CLIMATIC  THERAPEUTICS 


MEAN  RAINFALL  (in  inches  &  by  seasons) FOR 
DIFFERENT  PARTS  OF  THE  UNITED  STATES. 

•  PLACE  • 

VINTER 

SPRING 

SUMMER 

FALL 

SARANAC  LAKE,  NY 

74" 

^^ 

II  b' 

^_ 

PHILADELPHIA.  PA 

q.7' 

<1  5' 

II  1" 

15' 

ASHEVILLE.  N.C 

q.7" 

111' 

iS.fc" 

4L. 

AIKEN.  S.C. 

iij" 

lib' 

|I5  5" 

i£^__ 

COLORADO  SPRINCS.COL 

0  8" 

1 

4.5" 

7  0' 

1.0" 

ALBUQUERQUE,  NM 

i>o- 

I 

13" 

• 

3  4" 

^i^' 

SANTEFE,  NM. 

t  0" 

t 

^ 

33- 

PRESCOTT.  NM 

4.S" 

^ 

^ 

3  0' 

PHOENIX,  ARIZ 

2  1- 

[■"■ 

i"*' 

■'' 

YUMA,  ARIZ. 

■ 

0  4' 

0  4" 

Ob' 

LOS  ANGELES ,  CAL 

^^B 

10)' 

O.l' 

ZJ' 

SAN  DIEGO.  CAL 

5  4" 

2  4' 

0  3" 

■ 

Fig.  176. — Seasonal  Rainfall  in  American  Health  Resorts,  Compared  with 

Philadelphia. 

In  the  enumeration  of  resorts  which  follows,  and  which  makes  no 
pretense  to  comprehensiveness,  our  own  country  will  be  taken  up  first, 
various  parts  of  the  United  States  being  considered  in  turn.  Foreign 
resorts  will  also  be  discussed  briefly. 


UNITED    STATES    RESORTS 

New  England  States. — Although  one  State  in  this  section — Massa- 
chusetts— has  been  especially  prominent  in  its  official  activities  in  the 
prevention  of  tuberculosis  through  its  State  sanatorium  efforts,  one  would 
never  send  a  patient  to  the  New  England  States  because  of  the  climatic 
advantages  there  offered.  The  climate  throughout  the  year  is  character- 
ized by  great  changes  of  temperature  and  of  the  atmospheric  conditions. 
The  cold  of  winter  and,  except  in  the  mountainous  regions,  the  heat  of 
summer,  on  the  whole,  render  this  region  undesirable  from  the  phthisio- 
therapeutic  standpoint. 

During  the  summer  months,  the  interior  portions  of  Maine  and  the 
White  Mountains  of  New  Hampshire  present  suitable  -conditions  for 


ENUMERATION   OF   RESORTS 


701 


arrested  cases,  and  for  patients  in  the  incipient  stages  without  consti- 
tutional symptoms, 

Maine  presents  attractive  features  to  those  wishing  diversions,  owing 
to  its  fine,  large  forests  and  many  lakes,  which  make  excellent  hunting 
and  fishing  possible.  More  agreeable,  during  the  summer,  though  not 
so  beneficial  to  many  patients,  is  its  seacoast,  the  air  being  exhilarating 
even  when  fogs  prevail.  Along  this  coast  may  be  found  many  pleasant 
places  where  the  heat  is  never  intense. 

The  Adirondack  Mountains. — The  northern  part  of  ISTew  York  State 
has  an  altitude  of  1,500  to  3,500  feet.  On  account  of  the  pioneer  work 
of  Dr.  E.  L.  Trudeau,  this  section  is  internationally  considered  as  a 
suitable  resort  for  the  tuberculous.  The  same  cool  and  moist  conditions 
prevail  here  as  in  the  mountains  of  Maine  and  New  Hampshire. 

The  good  results  obtained  have  been  due,  however,  to  the  open-air 
treatment  methods  of  Dr.  Trudeau  rather  than  to  special  climatic  ad- 
vantages. Purity  of  air  is  an  important  factor.  The  winters  are  cold, 
with  much  snow,  when  the  air  feels  dry  and  bracing;  the  summers,  in 
general,  are  cool,  with  much  moisture.  Oppressive  heat  occurs  occasion- 
ally in  summer,  lasting,  however,  only  a  few  days.  As  in  all  other 
eastern  resorts,  great  changes  of  temperature  take  place.  The  region  is 
studded  with  many  small  lakes,  well  wooded,  and  has  an  abundance  of 
pure  water.  On  the  whole,  the  average  weather  is  of  the  cool  and 
cloudy  kind,  and  one  is  stimulated  by  the  crisp  air. 

The  principal  resort  is  Saranac  Lake,  and  a  short  distance  from  it 
is  Trudeau,  where  the  Adirondack  Cottage  Sanatorium  stands.  Weather 
conditions  of  the  four  seasons  covering  a  period  of  twelve  years  are  as 
follows : 

TABLE   V 
January  1,  1894,  to  December  31,  1903 


Saranac  Lake.  N  Y 

Essex  County 
(Altitude.  1.620  Feet) 


Winter  Mean. 
Spring  Mean .  . 
Summer  Mean 
Fall  Mean 

Annual  Mean . 


Mean  of 

Mean  of 

Mean 
Amount 
of  Rain 
in  Inches 

Number 

Mean 

the  Maxi- 

the Mini- 

of Days 

Average 

Tempera- 

mum 

mum 

with  0  01 

Depth  of 

ture 

Tempera- 
tures 

Tempera- 
tures 

or  More 
Rain 

Snow 

17 

27 

6 

7.4 

42 

60.4 

41 

52 

29 

7.8 

35 

20.-) 

64 

75 

52 

11.6 

36 

0.0 

45 

55 

35 

8.8 

35 

10.7 

42 

52 

31 

35.6 

148 

91.6 

Direc- 
tion of 

Pre- 
vailing 
Wind 


West. 
West. 
West. 
West. 

West. 


Adirondack  Cottage  Sanatorium  (1,750  feet),  some  distance  from 
the  town  of  Saranac  Lake,  receives  only  incipient  ca.ses,  and  is  intended 
only  for  poor  people  or  those  with  moderate  means,  and  all  api)lieations 


702  CLIMATIC  THERAPEUTICS 

have  to  be  made  through  the  town  office  in  Saranac  Lake.  It  is  well 
protected  from  strong  winds,  and  has  a  beautiful  outlook.  The  accom- 
modations include  every  comfort  for  the  nominal  sum  of  $5  a  week. 
This  institution  is  especially  mentioned,  as  being  one  of  the  great 
achievements  of  Dr.  Trudeau's  life.  By  means  of  the  results  obtained 
in  it  and  through  his  work  in  the  prevention  of  tuberculosis,  this  great 
man  has  been  an  inspiration  to  a  large  number  of  men  in  similar 
institutions  in  our  country.  The  M'ork  done  l)y  the  Adirondack  Cottage 
Laboratory,  under  the  excellent  guidance  of  Dr.  Trudeau,  has  been  as 
notable  as  the  results  ol)tained  in  the  sanatorium. 

Tliere  are  excellent  hotels  and  boarding  houses  in  Trudeau  where 
invalids  are  well  cared  for.  Other  resorts  are  Paul  Smith's,  Lake 
Placid,  and  many  smaller  places  where  good  accommodations  may  be 
had.  Around  several  of  the  towns  and  along  many  of  the  lakes  camp 
life  during  the  summer  is  made  a  very  attractive  feature. 

Sea  Breeze,  near  New  York,  with  a  typical  eastern  ocean  climate, 
has  shown  what  good  results  may  be  ol:)tained  at  the  seashore  in  the 
treatment  of  tuljerculous  diseases  of  children.  That  there  is  special 
value  to  be  derived  at  the  coast  for  children  is  now  recognized.  France 
was  the  first  country  to  establish  seaside  sanatoria  for  children,  and 
England  has  similar  institutions.  Brannan,  in  speaking  of  the  ef- 
fects of  this  climate  on  joint  tuberculosis,  writes :  "  The  strength- 
ening effect  of  the  sea  air  was  such  that  operations  such  as  must 
constantly  be  resorted  to  in  tuberculosis  of  tlie  bones,  joints,  and 
glands,  when  patients  live  in  cities,  are  rarely  necessary.  .  .  .  Sev- 
eral patients  wlio  were  unable  to  walk  when  they  came,  at  tlie  end 
of  two  or  three  months  were  able  to  run  about  and  play  with  the 
others." 

The  senior  surgeon  of  the  institution,  after  fifteen  years'  experience, 
says  that  the  knife  plays  a  secondary  part  to  climatic  and  general 
influences. 

New  Jersey. — The  northern  part  of  this  State  is  more  or  less  hilly 
and  well  wooded,  and  the  towns  are  adapted  for  suburban  residences. 
There  are  three  places — Lakewood,  Morristown,  and  Summit — that  pos- 
sess climatic  factors  for  a  winter  residence  to  invalids  who  cannot  go 
far  from  New  York.  Lakewood,  altitude  60  feet,  farther  south,  near 
the  ocean,  has  sandy  soil  and  a  climate  that  partakes  of  the  ocean 
climates.  It  is  more  equable,  has  a  greater  numl)cr  of  sunshiny 
days,  and  is  well  protected  by  pine  forests.  The  season  extends  from 
October  1  to  June  1.  According  to  Schauffler's  record  for  five  years, 
the  percentage  of  days  with  sunshine  averaged  eighty-four.  The  place  is 
supplied  with  fine  hotels,  but  is  too  fashionable  to  l)e  a  good  resort  for 
tuberculosis.     Morristown  and  Summit,  altitude  500  feet,  and  to  the 


ENUMERATION   OF  RESORTS 


703 


nortliwest,  are  colder  in  winter  and  cooler  in  summer.  They  are  quiet 
places,  with  comfortable  homes,  well  suited  for  the  outdoor  life  in  an 
eastern  climate. 

Pennsylvania  is  another  example  of  eastern  climate.  The  weather 
conditions  for  Philadelphia,  as  a  type,  may  be  contrasted  with  others 
of  the  South  and  West. 

The  Blue  Ridge  Mountain  region  lx)asts  of  pure,  comparatively  dry 
air  most  of  the  year,  with  porous  soil,  but  its  resorts  are  better  in 
winter,  since  the  summers  are  usually  hot.  Among  them  may  be  men- 
tioned Delaware  Water  Gap,  altitude  GOO  feet,  and  Glen  Summit,  alti- 
tude 2,000  feet.  Near  the  latter  place,  in  Luzerne  Covnty,  is  the  ^Vllite 
Haven  Hospital,  for  poor  consumptives  in  early  stages,  with  accommo- 
dations for  100  patients. 

The  following  record  for  Philadelphia  (Henr}',  'OG)  extends  over 
fifty  years : 

TABLE   VI 


Philadelphia. 

Pa. 

(AUitude,  42 

Feet) 

(a 

0. 

S 

.JL.  <i 

.S3 

"^1 

O  m 

s  _ 

c  == 

"o 
<  = 

>00 

5 
o 

CI 

t 

a)  a 
us 
cacc 

a 

..H 

C3  S 

?'3 

Eo 

es  0 
< 

3 

"a 

CI 

"a; 

< 

la 
P-. 

Winter  ^lean. 

34 

41 

27 

9.7 

34 

17.1 

76 

69 

156 

53 

N.  W. 

Spring  Mean . 

51 

60 

42 

9.5 

36 

4.1 

70 

64 

224 

55 

N.  W. 

SummerMean 

74 

83 

66 

11.9 

32 

0.0 

73. 

67 

275 

62 

s.  w. 

Fall  Mean. . .  . 

57 

64 

49 

9.5 

28 

1.0 

77 

70 

203 

60 

N.  W. 

Annual  Mean 

54 

62 

46 

40.6 

130 

22.2 

74 

67 

215 

57 

N.  W. 

The  Appalachians. — This  chain  of  mountains,  almost  paralleling 
the  Atlantic  coast,  extends  from  the  New  England  States,  on  the  north, 
to  Georgia,  on  the  south.  The  greatest  elevations  are  in  the  southern 
part,  and  there  the  altitudes  of  the  various  resorts  of  this  range  are 
sufficient  to  lower  the  prevailing  temperature  in  the  warm  season  of 
the  year.  All  along  the  Eastern  States  the  elevated  regions  of  this 
range  influence  the  climate  of  that  section,  rising  in  New  York  to  4,000 
feet  in  the  Catskills,  to  5,000  feet  in  the  Adirondacks,  and  in  New  Hamp- 
shire to  6,000  feet  in  the  White  Mountains.  In  the  south  Atlantic  States, 
North  and  South  Carolina  have  many  elevated  regions  on  this  range 
which  climatically  are  well  suited  for  the  treatment  of  tuberculosis. 
The  places  vary  from  1,000  to  3,000  feet  in  altitude,  and  are  adapted 
for  patients  who  may  not  be  sent  to  high  altitudes  or  too  near  the 
coast,  or  who  cannot  endure  severe  cold. 


704 


CLIMATIC  THERAPEUTICS 


Great  and  sudden  changes  of  temperature  throughout  the  Appala- 
chian range  may  occur  at  any  season,  as  in  other  eastern  climates. 

Asheville,  elevation  2,255  feet,  with  a  population  of  about  20,000, 
is  the  principal  resort  of  North  Carolina,  and  is  beautifully  situated, 
being  surrounded  by  hilly  country  and  fine  forests,  which  add  much 
to  its  attractiveness.  It  has  the  general  characteristics  of  mountain 
places,  possesses  a  good  climate  all  the  year  round,  the  summers  being 
more  equable  than  the  winters.  The  summer  is  cool  and  comparatively 
dry,  the  mean  of  the  maximum  temperatures  being  82°  F.,  with  relative 
humidity  of  65°  to  70°  F.,  and  an  annual  rainfall  of  42  inches.  The 
winters  are  cold,  some  days  having  frost  and  snow,  which  is  light  and 
disappears  quickly.  The  mean  of  the  minimum  temperatures  is  29°  F., 
which  gives  a  better  idea  of  the  winter  range  than  the  mean  average. 
Excellent  accommodations,  several  sanatoria,  and  plenty  of  amusing 
diversions  may  be  had.  A  patient  not  accustomed  to  high  altitudes, 
or  one  who  may  indulge  in  the  outdoor  life,  should  choose  Asheville. 
The  weather  conditions  of  Asheville  (Henry,  '06)  for  twenty-four  years 
were  as  follows: 

TABLE   VII 
August  1,   1857,  to  December  31,  1903 


Asheville,  N.  C, 

Buncombe  Co. 

(Altitude,  2  255  Feet) 

Mean 
Tempera- 
ture 

Mean  of 
the  Maxi- 
mum 
Tempera- 
tures 

Mean  of 
the  Mini- 
mum 
Tempera- 
tures 

Mean 
Amount 
of  Rain 
in  Inches 

Number 
of  Days 
with  0.01 
or  More 
of  Rain 

Average 

Depth  of 

Snow  in 

Inches 

Direc- 
tion of 

Pre- 
\'ailing 
Wind 

Winter  Mean 

Spring  Mean 

Summer  Mean .... 
Fall  Mean 

Annual  Mean 

39 
54 
71 

55 

55 

50 
66 

82 
68 

66 

29 
43 
60 
44 

44 

9.7 
11.1 
13.6 

8.2 

42.6 

27 
32 
36 
21 

116 

14.8 
1.5 
0.0 

Trace 

16.3 

West. 
West. 
West. 
West. 

West. 

Southern  Pines,  N.  C,  altitude  700  feet,  a  resort  with  the  low  in- 
land type  of  climate,  about  100  miles  from  the  coast,  is  milder  than 
Asheville  and  less  stimulating.  The  winters  are  moderately  cold,  with 
some  snow.  The  place  is  well  protected  from  winds,  and  has  a  sana- 
torium for  pulmonary  tuberculosis. 

Ail'en,  S.  C,  altitude  565  feet,  is  probably  the  most  popular  resort 
in  the  State  of  real  value  to  the  tuberculous.  The  variations  of  tem- 
perature and  the  relative  humidity  are  less  than  in  other  sections  of 
the  State.  The  winters  are  mild  and  well  known  for  the  great  number 
of  sunny  days.  The  town  is  well  protected  by  forests,  has  limited 
accommodations  and  a  sanatorium — the  Aiken  Cottages — for  the  poorer 
class. 

The  winter  mean  temperature  is  48°  F. ;  mean  of  the  maxima,  56° 


ENUMERATION   OF   RESORTS 


705 


F. ;  mean  of  the  minima,  39°  F. ;  relative  liumiclity,  <i5  to  til)  per  cent. 
Summer  mean  temperature,  78°  F. ;  mean  of  the  maxima,  86°  F. ;  mean 
of  the  minima,  T0°  F. ;  relative  humidity,  6T  to  72  per  cent. 

Augusta,  (Ja.,  altitude  139  feet,  and  North  Augusta,  S.  C,  sepa- 
rated by  the  Savannah  River,  which  divides  the  two  States,  are  climat- 
ically very  similar,  and  resemble  Aiken.  Both  are  delightful  places  in 
which  to  pass  the  winter.  Xorth  Augusta  is  about  500  feet  higher  than 
Augusta,  and  on  account  of  this  will  be  chosen  by  those  who  wish  the 
increased  elevation;  otherwise  the  meteorologic  factors  are  essentially 
the  same. 

Life  in  the  open  air  may  be  followed  advantageously,  and  is  attrac- 
tive in  these  places,  with  many  amusements  for  those  ^yho  have  the 
time.  The  former  drawbacks  of  these  resorts — the  inadequate  accom- 
modations and  poor  food  for  those  seeking  health — have  been  removed, 
and  Coleman,  who  goes  into  details  in  regard  to  these  places,  says  that 
one  may  now  live  and  travel  in  luxury  here  as  in  any  portion  of  the 
country   (Henry,  'O(i). 

TABLE   VIII 
1875-1903 


Tem 

PERATURF. 

Precipitation 

Mean- 
Humidity 

Tg-fal 
Sunshine 

Augusta,  G\. 

a 

0) 
JZ 

—  s 
'o  .E 

I5 

)er  of 
with 
r  More 
in 

9  ■ 

<u 

0 

•is 

Day.s 

0.01   0 

Ra 

too 
X 

|=c 

V  c 
0,0 

£5 

Winter  Mean ... 

48 

58 

39 

12.1 

30 

83 

67 

168 

54 

West. 

Spring  Mean 

64 

/.) 

53 

11.8 

29 

77 

57 

257 

64 

West. 

Summer  Mean.  .  . 

80 

90 

70 

15.4 

36 

82 

70 

322 

76 

S.  E. 

Fall  Mean 

65 

75 

55 

9.2 

21 

84 

69 

228 

65 

N.  E. 

Annual  Mean. .  . 

04 

74 

54 

48.5 

116 

82 

66 

244 

()5 

^^•e.st. 

In  these  warm  and  moderately  moist  places,  patients  in  the  early 
stages  of  tuberculosis,  or  in  the  fibroid  stage,  and  those  who  do  not 
bear  altitude  well,  will  find  the  winter  very  agreeable.  The  best  season 
is  from  November  to  April. 

Savannah,  Ga.,  and  Charleston^  S.  C,  have  the  warm  ocean  climates 
of  the  Atlantic  coast,  and  on  account  of  the  disadvantages  of  large  cities 
are  not  to  be  recommended. 

Atlanta,   Ga.,  altitude    1.0.59   feet,  has  an  excellent   climate   of  the 

low  inland  type.     The  best  season  is  the  spring — the  months  of  March, 

April,  and  May — which  is  true  of  most  of  the  southern  climates,  when 

the  relative  humidity  is  lowest.     Occasionally  it  is  very  cold  in  winter, 

46 


706 


CLIMATIC  THERAPEITTICS 


as  low  as  5°  to  8°  F.  below  /.cro,  and  in  suniiner  may  reach  95°  F.  For  a 
period  of  ten  years  the  mean  temperature  for  winter  was  about  44°  F. ; 
for  summer,  77°  F.  The  mean  relative  humidity  through  the  daytime 
for  wdnter  is  68  to  81  per  cent;  for  spring  it  is  59  to  76  per  cent;  for 
summer  it  is  68  to  82  per  cent,  and  for  the  fall  it  is  65  to  80  per  cent. 

Tliomasville,  Ga.,  altitude  330  feet,  is  a  well-known  winter  resort. 
It  is  situated  in  the  soutliern  part  of  Georgia;  it  is  warmer  than  tlie 
otlier  resorts,  and  has  a  higher  relative  humidity,  except  in  the  winter 
time.  Tlie  air  is  very  mild  throughout  the  winter  and  spring  months, 
and  suited  to  those  who  do  not  bear  cold  weather  well.  The  spring 
often  is  warm,  and  the  summer  too  warm  for  comfort.  The  mean 
annual  temperature  is  about  67°  F. ;  53°  F.  for  the  winter  and  81°  F. 
for  the  summer. 

Florida. — In  general,  the  climate  of  Florida  is  equable,  moist  and 
warm.  Florida  has  a  peculiar,  interesting  scenerv  of  its  own,  and  the 
large  resorts  afford  most  excellent  hotel  accommodations.  The  resorts 
in  Florida  formerly  were  recommended  for  tuberculosis  on  account  of 
the  ecpiable  climate  and  because  of  the  adequate  accommodations.  As 
the  resorts  in  better  climates  have  been  made  suitable  and  comfortable, 
fewer  patients  are  being  sent  to  Florida.  Florida  suffers  less  than  most 
eastern  places  from  the  sudden  changes,  but  cold  waves  occur  during 
the  winter,  when  the  temperatnre  may  fall  to  the  freezing  point.  The 
mildness  in  winter,  the  scenery,  and  tlie  fine  hotels  are  the  chief  at- 
tractions. 

JachsonviUe,  St.  Augustine,  Tampa,  and  small  places  along  the  St. 
John  River  are  favorite  resorts  for  January,  February,  and  March.  The 
weather  statistics  for  Jacksonville  (Henry,  '06)  for  thirty-two  years  are 
shown  in  the  following  table : 


TABLE   IX 

1871-190.3 


Temperature 

Precipitation 

Mean 
Humidity 

Total 
Sunshine 

01 

Jacksonville. 
Fla. 

5 

01 

C  cS 

gs 
s 

65 

78 
90 

78 

78 

01 

JZ 

'o-H 

47 
60 
73 
63 

61 

c 

s 

'S, 

Number  of 

Days  with 

0.01  or  More 

Rain 

1* 

■  —  s 

1- 

o>  „ 

2  5 

0)  0 

a  6 

0><u 

PL,  0 

Direction  of 
vailing  Wi 

Winter  Mean .... 

Spring  Mean 

Summer  Mean . .  . 
Fall  Mean 

Annual  Mean .... 

56 
69 
81 
70 

69 

9.4 
10.4 
17.9 
15.7 

53.4 

27 
24 
42 
32 

125 

84 
78 
81 
85 

82 

76 
70 

78 
80 

76 

163 
281 
267 
183 

223 

51 
71 
64 
52 

60 

N.  E. 
N.  E. 
S.  W. 

N.  E. 

N.  E. 

ENUMERATION   OF   RESORTS  707 

Rocky  Mountain  Resort  Region. — This  n-yioii  comprises  Coluj-adu, 
Utah,  New  Mexico,  the  western  part  of  Texas,  Arizona,  and  a  small 
strip  of  the  eastern  part  of  soutliern  California.  This  whole  region 
has  similar  characteristics,  possessing  dryness,  elevation,  and  abundance 
of  sunshine  throughout  the  year.  The  air,  on  the  whole,  is  nearly 
always  .stimulating  and  cool,  except  in  certain  parts  of  the  southwest 
district,  where  the  altitude  is  insuflficient.  So  far  as  the  climate  is 
concerned,  tliis  wliole  region  is  a  suita])le  and  natural  resort  for  those 
affected  with  ])ulmonary  tul)erculosis.  For  resorts  having  a  high  eleva- 
tion, Colorado  and  Xcw  JMexico  must  be  selected.  There  the  winters 
are  cold,  with  many  days  of  low  tcuiperature.  The  southern  parts  of 
New  Mexico  and  Arizona  have  warmer  temperatures,  with  sites  for 
ideal  winter  resorts,  and  are  equable  and  dry  and  have  many  sunny 
days. 

The  eastern  strip  of  California  belonging  to  this  region  will  not 
he  considered,  as  it  is  uninhabitable  and  unfit,  in  its  present  condition, 
for  resorts. 

In  the  Hocky  Mountain  region  rain  falls  chiefly  in  summer,  in 
the  form  of  sliowers  which  interfere  little  with  the  sunshine.  In 
the  southern  part,  from  the  continental  divide  east  over  the  Colo- 
rado desert,  through  and  including  El  l*aso,  rain  falls  in  midsummer. 
This  is  in  contrast  to  the  racific  Ocean  region,  where  the  rain  falls 
in  winter. 

In  the  East  and  along  the  Atlantic  coast  the  winters  are  rough  and 
cold,  while  in  the  Kocky  Mountain  and  Pacific  coast  regions  the  winters 
are  warmer,  more  equable,  and  clearer.  The  reverse  of  this  seems 
equally  true,  and  although  there  are  no  statistics  to  offer,  the  Avriter's 
twelve  years'  experience  on  the  Pacific  coast  has  given  him  this  im- 
pression. 

The  northern  part  of  this  region,  especially  Colorado,  may  be  com- 
pared to  the  higher  mountain  resorts  of  the  Alps,  with  the  same  indi- 
cations for  tuberculous  cases,  while  the  southern  half — the  arid  district 
— has  no  similar  continental  region.  The  great  advantage  of  the  Alpine 
region  is  that  the  deep  snow  which  covers  the  ground  during  tlie  entire 
winter  absolutely  prevents  any  irritation  of  dust  which  is  met  with  in 
so  many  other  resorts. 

Colorado.— The  elevation  of  this  State  varies  from  4,000  to  10,000 
feet,  with  mountain  peaks  over  14,000  feet  in  height.  Though  there 
are  many  health  resorts  at  different  elevations,  there  are  only  a  few  to 
be  mentioned  that  have  gained  great  reputations. 

Solly,  J.  E.  ('07),  states  that  "for  the  purpose  of  health  resort 
stations  the  climate  of  Colorado  may  be  divided  into  three  groups: 
Firftt,  the  prairie  plains,  ranging  from  4,000  to  6,000  feet;  second,  the 


708  CLIMATIC  THERAPEUTICS 

fuot-liills  aud  adjoiuijig  valleys,  varyiii<i-  from  (),()0()  to  7,000  feet;  Ihird, 
the  natural  parks,  varying  from  7,000  to  10,000  feet  elevation." 

Characteristic  features  of  the  State,  hesides  the  elevation  and  the 
great  distance  from  the  ocean,  are  low  relative  liumidity,  large  range 
of  temperature,  and  an  abundance  of  sunshine,  the  prevailing  winds 
being  west.  The  climate  of  the  eastern  and  southeastern  parts  is  l)etter 
than  that  of  the  western  part.  The  mean  temperature  of  the  eastern 
section  for  winter  is  slightly  above  30°  F. ;  mean  of  the  maxima  vai'ies 
from  40°  to  49°  F. ;  mean  of  the  minima,  12°  to  18°  F. ;  mean  for  th(3 
summer,  70°  to  76°  F.  Mean  of  the  maxima  in  the  southeastern  part  is 
90°  F. ;  68°  F.  in  the  central  part;  mean  of  the  minima  in  central  moun- 
tain places  is  61°  to  35°  F.  The  average  relative  humidity  is  48  to  50 
per  cent.  When  high  temperatures  prevail,  the  humidity  is  very  low. 
The  average  sunshine  is  from  65  to  75  per  cent  of  the  possible.  From 
the  above  it  will  be  noted  that  the  summers  are  always  cool  and  dry ; 
the  winters  are  cold,  and,  compared  with  other  seasons,  the  greatest 
changes  of  temperature  occur  at  that  time.  There  are  marked  diurnal 
variations  throughout  the  year. 

The  indications  for  the  resorts  of  Colorado  are  those  given  for  high 
altitudes.  There  is  no  better  mountain  climate  than  that  of  Colorado 
for  pulmonary  tuberculosis,  or  a  climate  that  Avill  agree  with  more 
patients.  The  objections  are  the  occasional,  severe  cold,  the  sudden 
temperature  changes  of  winter,  and  the  strong  winds  of  spring  and  fall. 

Denver  has  an  altitude  of  5,183  to  5,600  feet.  The  business  center 
is  just  one  mile  above  sea  level.  Denver  is  an  active,  busy  city,  large  and 
beautifully  laid  out,  on  the  western  edge  of  the  great  plains.  It  is  the 
best  known  and  principal  health  resort  in  Colorado.  Its  growth  since 
1875  has  been  tremendous,  reaching  now  about  180,000,  so  that,  on 
account  of  its  size,  it  is  now  less  suitable  for  many  tuberculous  patients 
than  it  was  in  former  years.  It  has  every  advantage  of  a  large  modern 
city,  with  beautiful  stone  and  brick  residences,  wide  streets,  and  well- 
cared-for  grounds.  It  possesses  advantages  over  other  places  in  Colorado 
in  that  one  may  find  congenial  companionship,  earn  a  livelihood  in  a 
growing,'  busy  city,  or,  after  one  is  well  enough,  enter  business  life. 
This  is  not  to  be  underestimated  when  one  must  change  climates.  On 
the  other  hand,  it  is  not  to  be  forgotten  that  it  is  often  difficult  for 
invalids,  on  account  of  the  great  demand  for  positions,  to  obtain  suitable 
employment  unless  they  have  friends  in  the  place  to  render  assistance. 

Advantages  of  Denver  are  (1)  the  good  care  and  accommodations 
to  be  obtained;  (2)  the  pure  air,  stimulating  and  cool;  (3)  the  large 
amount  of  sunshine,  and  (4)  the  dry  atmosphere.  Objections  are  (1) 
the  strong  winds,  with  fine  dust  in  the  spring  and  fall,  and,  to  young 
people,  (2)  the  temptations  of  a  large  city. 


ENUMERATION    OF   KESOKTH 


709 


The  following  weather  statistics  cover  thirty-one  years  exeqjt  the 
sunshine  figures,  which  are  for  fourteen  years,  and  the  humidity  aver- 
ages, which  cover  fifteen  years.  During  this  time  the  lowest  tempera- 
ture of  winter  occurred  in  January  (29°  F.  below  zero)  and  in  March 
(11°  F.  below  zero). 

TABLE   X 

Denver 

Records  from  January  1,  1873,  to  December  31,  1903 


Tem 

PERATnRE 

Precipitation 

Mean 
Humidity 

Total 
Sunshine 

V 

(1) 

o 

=  S: 

Seasons 

5 

—   03 

o.s 
1-= 

J3 

Mean 

Days  with 

OOl'or  Mor 

Rain 

0-00 

K 

6 

a;  c 

S— 

Direction 
vailing 

Winter  Mean .  .    . 

31 

44 

18 

1.7 

15 

59 

49 

200 

69 

South. 

Spring  Mean 

48 

61 

35 

5.4 

26 

63 

39 

266 

65 

Soutli. 

Summer  Mean.    . 

70 

84 

56 

4.4 

25 

63 

34 

296 

68 

South. 

Fail  Mean 

51 

65 

37 

o  2 

14 

57 

35 

243 

74 

South. 

Annual  Mean. . . 

50 

63 

37 

13.7 

80 

61 

39 

251 

69 

South. 

There  are  excellent  hotels  and  good  l)oarding  houses  in  Denver,  and 
several  sanatoria.  "  The  Home."  near  the  center  of  Denver,  is  under 
the  direct  ownership  and  management  of  the  Episcopal  church  of  the 
diocese.  The  regular  terms  are  $25  per  week.  The  Agnes  Memorial 
Sanatorium  is  situated  in  the  suburbs;  terms  are  $7  to  $10  per  week, 
with  preference  given  to  applications  from  western  Pennsylvania.  "  The 
Associated  Health  Farm  "  was  organized  by  the  Young  Men's  Christian 
Association.     There  are  several  other  institutions. 

Colorado  Springs,  altitude  6.098  feet,  is  the  next  important  health 
resort  in  the  State.  It  is  beautifully  situated  for  a  resort,  being  sur- 
rounded by  high  mountains,  with  the  base  of  Pike's  Peak  six  miles 
distant.  It  has  a  porous  soil,  an  excellent  system  of  drainage,  a  fine 
supply  of  Avater,  a  population,  including  suburbs,  of  about  42,000,  fine 
wide  streets  and  extensive  grounds,  which  impress  the  stranger  wnth  the 
feeling  that  the  open-air  life  is  well  carried  out.  The  building  of  this 
town  as  a  suitable  resort  is  due  largely  to  the  help  of  General  W.  J. 
Palmer.  It  has  all  the  climatic  advantages  of  Denver,  and  in  addition 
the  open-air  life  of  a  distinct  open  resort  is  everywhere  present  with  none 
of  the  disadvantages  of  a  large  city.  Its  most  seriotis  drawbacks  are  the 
excessive  wind  and  dust  storms,  which  prevail  in  spiiug  and  occasion- 
ally in  the  fall,  against  which  invalids  niusl  be  protected. 


710  CLIMATIC  THERAPEUTICS 

The  temperature  for  the  whole  year  is  cooler  than  in  Denver,  the 
mean  annual  reading  47°  F.,  as  against  50°  F. ;  the  mean  of  the  maxima 
is  60°  F.,  as  against  63°  F. ;  the  mean  of  the  minima  is  34°  F.,  as  against 
37°  F.  This  makes  the  warm  months  of  spring,  summer,  and  fall  more 
agreeahle,  and  for  many  temperaments  Colorado  Springs  is  much  better 
than  Denver.  When  snow  falls  in  winter  it  does  not  remain  on  the 
ground  for  any  length  of  time.  The  mean  precipitation  is  about  the 
same  as  in  Denver — 13  to  14  inches.  Colorado  Springs  has  fine  hotel 
accommodations,  and  also  many  good  boarding  houses.  The  closed  re- 
sorts have  not  been  greatly  developed.  The  one  to  be  recommended  for 
tuberculous  patients  only  is  "  Craigmore,"  started  by  Solly  and  reopened 
this  year,  with  excellent  care  and  accommodations.  Rates  are  $25  to 
$35  per  week.  The  other  institution  recommended  is  "  The  Glockner 
Sanatorium,"  a  sanatorium  for  all  kinds  of  cases  and  not  only  tuber- 
culous patients.     Terms  are  $8  to  $40  per  week. 

Manitou,  altitude  6,300  feet,  is  five  miles  west  of  Colorado  Springs, 
at  the  foot  of  Pike's  Peak,  and  well  sheltered  from  strong  Avinds.  The 
drives  about  Manitou  and  Colorado  Springs  are  a  most  pleasing  feature 
of  this  region. 

Glenwood  Springs,  altitude  5,200  feet,  is  a  summer  resort  for  rheu- 
matic and  pulmonary  invalids.  It  has  a  very  comfortable  hotel,  but  is 
not  recommended  as  a  resort. 

Pueblo,  altitude  4,700  feet,  is  a  small  manufacturing  city  which  has 
mild  and  very  dry  winters,  but  very  warm  summers.  There  are  few 
good  accommodations,  and  it  is  not  recommended  as  a  resort. 

Ego-la,  Estcs,  Antelope,  and  Manitou  Paris,  and  Palmer  Lake,  all 
higher  than  Denver  and  Colorado  S])rings,  are  sheltered  valleys,  more 
or  less  known  as  summer  resorts,  and  in  some  of  them  good  board  may 
be  obtaim-d   (Solly  (S.  E.),  '97). 

New  Mexico.— This  State  has  an  altitude  from  3,000  to  5,000  feet, 
and  extends  from  latitude  32  degrees  to  latitude  37  degrees.  Most  of 
the  rain  falls  in  summer,  l)ut  only  during  a  part  of  the  day  in  July  and 
i\.ugust,  so  that  throughout  the  year  a  large  amount  of  sunshine  is 
present,  being  at  a  maximum  in  the  fall  and  winter.  High  winds  are 
frequent  in  the  early  spring.  The  annual  mean  temperature  is  54°  F. ; 
the  winter  average  is  36°  F.  and  the  summer  average  is  72°  F.  The 
average  annual  precipitation  is  13  inches  and  the  mean  relative  humid- 
ity about  40  per  cent. 

The  climate  of  the  resorts  in  the  northern  part  of  the  State  is  similar 
to  the  Colorado  climate,  but  there  are  few  good  weather  statistics  for 
the  different  portions  of  the  State.  Xew  Mexico  possesses  an  excellent 
climate,  adapted  for  an  outdoor  life  during  the  whole  year.  The  most 
serious  objections  to  the  climate  are  the  severe  winds  in  the  early  months 


ENUMERATION   OF   RESORTS  711 

of  spring,  and  in  many  jilaccs  the  lack  of  good  accommodation;-  and 
food. 

Santa  Fe  (altitude  7,013  feet),  Las  Vegas  (altitude  6,500  feet), 
and  Albuquerque  (altitude  5,200  feet)  are  three  cities  in  the  northern 
part  of  Xew  Mexico,  on  the  line  of  the  Santa  Fe  Railroad,  and  are  the 
best-known  resorts.  The  climate  of  thiBse  places  is  very  similar  to  that 
of  Denver.  Ten  years'  record  of  the  weather  bureau  shows  that  the 
winter  temperature  in  the  al)ove  resorts  does  not  fall  so  low  as  that 
of  Denver,  nor  is  the  summer  temperature  as  high.  The  humidity  is 
less,  and  in  Santa  Fe  there  is  less  wind.  An  exception  might  be  made 
of  Las  Vegas,  the  summer  temperature  of  which  is  higher,  though  we 
have  no  proved  record  of  the  fact.  Santa  Fe,  in  a  ten  years'  record, 
shows  a  winter  mean  temperature  of  31°  F. ;  summer,  67°  F. ;  the 
lowest  for  winter  is  13°  F.  below  zero;  the  highest  during  summer  is 
07°  F.  The  relative  annual  mean  humidity  is  55  per  cent  at  8  a.m.  and 
3()  per  cent  at  8  p.m.,  with  an  average  of  279  hours  of  total  sunshine 
for  the  month.  The  prevailing  wind  is  southeast,  and  is  less  intense 
during  any  part  of  the  year  than  in  either  of  the  other  places. 

Las  Vegas  is  warmer  and  dustier  in  shimmer  than  Santa  Fe;  has 
higher  winds  in  spring,  with  much  the  same  fine  winter  climate. 

Albuquerque  is  warmer,  both  in  winter  and  summer,  than  Santa  Fe, 
has  less  precipitation,  but  has  severer  and  more  frequent  winds.  The 
mean  temperature  for  winter  is  35°  F. ;  for  summer  it  is  76°  F. 
The  lowest  temperature  is  10°  F.  below  zero;  the  highest  is  104°  F.  The 
prevailing  wind  is  south.  The  annual  mean  rainfall  is  7.2  inches,  while 
Santa  Fe  has  14.2  inches.  Albuquerque  is  a  most  thriving  and  pro- 
gressive city,  and  better  accommodations  and  food  may  be  obtained  there 
than  in  Santa  Fe,  but  the  climatic  conditions  are  not  so  favorable.  On 
account  of  the  lower  hum.idity  and  the  greater  amount  of  sunshine,  these 
resorts  would  be  better  than  either  Denver  or  Colorado  Springs  if  the 
climate  alone  were  to  be  considered,  but  the  resorts  of  Colorado  possess 
the  other  factors  so  necessary  in  climatotherapy.  There  are  sanatoria 
and  limited  accommodations  at  each  of  these  three  places. 

The  principal  resorts  of  the  southern  part  of  Xew  Mexico  to  be  here 
considered — Deniing,  Silver  City,  Fort  Bayard — are  situated  in  the 
southwestern  region.  El  Paso  and  Texas  will  be  included  with  the 
others,  as  having  similar  climatic  conditions  and  representing  western 
Texas.  Each  has  an  ideal  winter  temperature,  with  as  low  humidity 
and  as  much  sunshine  as  can  be  found  anywhere  in  the  Eocky  Moun- 
tain region.  Silver  C!ity  and  Fort  Bayard,  in  summer,  are  comfortably 
cool,  with  few  hot  days,  owing  to  tlie  liigli  altiludc,  while  Deming  and 
El  Paso  arc  too  warm  for  comfort. 

Deming,  altitude  4,315  feet,  is  250  miles  south  of  Albuquerque; 


712 


CLIMATIC  THERAPEUTICS 


has  an  ideal  winter  climate,  but  limited  accommodations.  Silver  City, 
altitude  6,000  feet,  is  50  miles  northwest  of  Deming,  and  as  comfortable 
a  place  for  the  tuberculous  as  will  be  found  in  this  region,  with  a 
choice  of  three  sanatoria,  and  here  one  may  find  comfort  the  year 
around.  The  mean  annual  temperature  is  54°  F. ;  the  relative  humid- 
ity is  46  per  cent;  the  rainfall  is  12.3  inches,  with  thirty-seven  cloudy 
days  in  the  year  (Bullock,  '02). 

About  seven  miles  from  Silver  City  is  the  government  sanatorium, 
Fort  Bayard,  for  the  officers  and  men  of  the  United  States  army.  Tiie 
place  was  chosen  as  offering  some  of  the  best  climatic  advantages  in  the 
United  States   (Bessey,  '03). 

To  contrast  the  weather  conditions  of  the  high  and  medium  alti- 
tudes of  this  region,  the  statistics  for  Fort  Bayard  and  El  Paso  (Henry, 
'OG)   are  sho\\Ti  in  the  following  tables: 


TABLE   XI 
1895-1903 


Temperature 

Precipitation 

Average 
Depth 

of 
Snow 

in 
Inches 

Fort  Bay.\rd, 

Xew  Mexico 

Altitude,  6,040  Feet 

C    0! 

is 

c 

4) 

Number  of 

Days  with 

001  or  More 

Inches  of 

Rain 

Direction  of 

Pre\ailing 

Wind 

Winter  Mean 

Spring  Mean 

Summer  Mean 

Fall  Mean 

39 
53 

72 
57 

55 

54 
69 
86 
71 

70 

25 
58 
57 
42 

40 

2.6 
1.2 
6.6 
3.6 

14 

8 

5 

24 

12 

7.2 
1.3 
0.0 

0  8 

West. 
West. 
West. 
Southwest. 

Annual  Mean 

49 

9.3 

West. 

TABLE   XII 

1879-1903 


Temperature 

Precipitation 

.\verage 
Depth 

of 

Snow  in 

Inches 

in  24 

Hours 

Mean 
Humidity 

Direc- 

El Paso,  Texas 
Altitude.  3.702  Feet 

Mean 

Mean  of  the 
Maxima 

Mean  of  the 
Minima 

c 

Number  of 

Day.swithO  01 

Inches  ()r 

More  Rain 

>  J. 

tion 
of 

Pre- 
vailing 
Wind 

Winter  Mean 

Spring  Mean . 
Summer  Mean. . 
Fall  Mean 

Annual  Mean 

47 
64 
80 
63 

63 

60 

79 
94 

77 

77 

33 

50 
68 
50 

50 

1.4 

0.9 
4.4 
2.6 

9.3 

9 

5 

20 

13 

47 

2 

0.1 
0.0 
0  3 

2.4 

58 
38 
55 
60 

53 

32 

15 
26 
31 

26 

N.  W. 
N.  W. 
E 
E. 

N.  W. 

ENUMERATION   OF   RESORTS  713 

Arizona  lias  climatic  advantages  similar  to  those  found  in  Xew  Mex- 
ico. In  general  the  winters  are  warmer,  the  summers  hotter,  and  the 
mean  humidity  is  less.  The  high  altitudes  have  snow  in  the  winter, 
and  there  is  no  section  of  the  State  entirely  free  from  frost.  Unlike 
Xew  Mexico,  the  Pacific  coast  makes  its  influence  felt  here,  and  tliere 
are  two  rainy  seasons,  winter  and  summer,  though  the  greatest  rain- 
fall occurs  in  July  and  August.  The  least  precipitation  is  in  the 
southern  and  southeastern  part,  amounting  annually  to  less  tlian  three 
inches. 

The  advantages  of  Arizona  are  (1)  pure  air;  (2)  the  great  amount 
of  sunshine;  (3)  the  dryness;  (4)  the  mild  winters;  (5)  in  the  ele- 
vated regions  of  the  northern  half,  cool  summers;  (G)  few  bad  storms 
of  any  kind.  Mean  temperature  is  60°  to  65°  F. ;  relative  humidity, 
30  to  50  per  cent.  This  mean  temperature  gives  little  idea  of  the  actual 
heat  that  exists  in  some  places  during  the  summer,  when  the  tempera- 
ture in  the  lower  district  is  110°  to  120°  F.  At  Fort  Mojave  a  record 
of  127°  F.  was  made  in  June,  1896. 

The  objection  to  Arizona  is  that  it  is  lacking  in  modern  towns  or 
places  where  suitable  accommodations  may  be  had.  In  most  of  the 
towns  it  is  almost  impossible  to  get  first-class  food  or  care.  Except  in 
a  few  i-esorts,  there  is  an  insufficient  water  supply.  Dust  storms  and 
high  winds  occasionally  occur  in  spring.  The  .summers  are  uncomfort- 
ably warm  anywhere  except  in  the  highest  altitudes. 

Prescott,  altitude  5,260  feet,  and  Flagstaff,  altitude  7,000  feet,  for 
all  year  round  resorts  are  the  two  places  recommended.  Part  of  the 
summers  may  be  hot,  and  the  spring  may  have  dusty  days.  The  accom- 
modations are  not  good  in  either  place.  Flagstaff  is  beautifully 
situated,  having  nearby  forests  of  tall  pines  and  many  interesting 
canons. 

Of  the  lower  elevations  recommended  for  winter  climates  only,  the 
principal  resort  is  Phcenix,  with  an  altitude  of  1,087  feet.  This  town 
is  favorably  situated,  and  well  kno^^^l  for  its  mild  winters,  low  humid- 
ity, and  large  amount  of  sunshine.  A  distinguishing  and  valuable  char- 
acteristic is  the  absence  of  wind  and  dust  storms.  Here  suitable  accom- 
modations may  be  had,  and  good  care  is  given  to  the  invalid;  but  the 
place  is  not  prepared  to  care  for  a  large  number,  and  arrangements  had 
best  be  made  before  going.  Tempe,  near  Phoenix,  has  the  same  climatic 
advantages.  Tucson,  altitude  2,400  feet,  in  the  southwestern  part  of 
the  State,  has  an  ideal  winter  climate,  and  can  be  recommended  from 
December  to  April.  The  accommodations  have  improved  in  the  last 
few  years,  and  patients  needing  this  medium  altitude  always  improve. 

The  following  tables  for  Phoenix  and  Prescott,  types  of  low  and 
high  altitudes  of  Arizona,  are  here  given: 


714 


CLIMATIC  THERAPEUTICS 


TABLE   XIII 

Phcenix,  Arizona.     Altitudk,  1,087  Fekt 

Record  from  January  1,  1896,  to  December  31,  1903  (Henry,  '06). 


Temper.-vture 

Precipitation 

Humidity 

i 

a) 
c 

P»  ? 

0  — 

u. 

Seasons 

0/ 

J2    ^ 

2 

ler  of 
itliOOl 
es  or 
Rain 

(L 

.2^ 

3s 

S  3 

,-  i 

a!  < 

SCO 

r^ 

c3  5- 

2?^ 

f. 

§£  =  = 

K** 

5 

0)  m. 

> 

Winter  Mean 

53 

66 

39 

2  2 

9 

61 

32 

E. 

79 

243 

Spring  Mean 

67 

82 

53 

1.0 

o 

45 

19 

E. 

85 

338 

Summer  Mean .... 

88 

102 

74 

1.9 

12 

45 

19 

E. 

86 

369 

Fall  Mean 

72 

86 

57 

1.7 

8 

53 

28 

E. 

86 

297 

Annual  Mean  .... 

70 

84 

56 

6.8 

34 

51 

25 

E. 

84 

312 

TABLE   XIV 

PrescottJ  Arizona      Altitude,  5.260  Feet  (Henry,  '06). 

Record  from  1876-1903.      (Irregularly.) 


Temperatdre 

Precipitation 

Average 

Depth  of 

Snow 

in 
Inches 

c  55 

11 

0) 

0.^ 

Seasons 

d.S 

a 

Number  of 

Days  with  0.01 

Inches  or 

More  Rain 

1^ 

Winter  Mean 

Spring  Mean 

Summer  Mean 

Fall  Mean 

Annual  Mean 

37 
50 
60 
53 

52 

50 
67 
86 
70 

68 

23 
36 
55 

38 

38 

4.5 
2.8 
5.3 
3  0 

15.6 

15 
11 
23 
11 

60 

13.2 
7.4 
0  0 

1.8 

22.4 

58 
47 
49 
50 

51 

s.  w. 
s. 

s  w. 
s.  w. 

s.  w. 

There  are  places  in  Arizona  and  in  southern  California,  east  of  the 
coast  range,  that  are  ahove  and  below  sea  level,  and  as  dry  as  any  places 
where  there  is  abundant  sunshine.  These  are  really  desert  climates, 
examples  of  which  are  Yuma,  Ariz.,  with  an  altitude  of  140  feet,  and 
Palm.  Springs,  Cal.  It  is  unfortunate  that  there  are  few  accommoda- 
tions for  invalids,  and  that  the  summers  are  intensely  hot. 

California. — The  northern  part  of  California  (McAdie,  '02)  is 
mountainous  and  picturesque,  with  much  moisture  for  the  abundant 
vegetation  that  is  present.  It  is  mostly  uninhabited,  and  in  general 
unsuited  for  tuberculous  patients  except  for  two  or  three  months  in 
the  summer.     At  that  time  of  the  year  the  elevated  parts  in  the  Mt. 


ENUMERATION   OF   RESORTS  715 

Shasta  region  are  coo!  and  iiivi^^orating.  These  mountainous  districts 
are  only  used  as  a  sojourn  for  summer  outing  by  a  few  patients  who 
need  a  cool,  elevated  place  as  a  change  from  the  inland  regions  or  the 
warm  places  of  southern  California. 

Southern  California  (Edwards,  '02) — that  is,  the  part  of  the  State 
hounded  on  the  north  by  the  mountains  which  meet  the  coast  at  Point 
Conception,  al)ove  Santa  Barbara,  and  on  the  east  by  the  coast  range — 
is  tlie  region  which  mostly  concerns  the  phthisiotherapist.  All  of  this 
district  partakes,  more  or  less,  of  a  coast  climate,  modified  l)y  nearness 
to  the  Colorado  desert  and  Arizona.  Places  on  the  coast  and  up  to 
1,000  feet  elevation  are  cool,  moderately  moist  in  fall  and  winter,  warm 
and  moist  in  spring  and  summer.  The  afternoons  are  always  less  moist 
than  the  mornings,  and  a])proach  relative  dryness.  Inland  60  miles, 
or  at  about  1,000  feet  elevation,  it  is  warm  and  luoderately  dry  in 
winter,  hot  and  moderately  dry  in  summer. 

Although  it  is  said  with  truth,  owing  to  the  diversified  topography, 
that  slight  changes  of  location  may  give  one  a  very  different  climate, 
it  is  impossil)le  to  live  in  an}-  degree  of  comfort  in  many  of  the  regions. 
Some  have  no  accommodations,  others  no  suitable  food,  and  others  no 
vegetation  of  any  kind.  Practically,  the  regions  where  one  can  find 
comfort,  contentment,  and  happiness  throughout  the  whole  year  are 
along  or  near  the  coast,  and  these  regions  are  not  as  desirable  climat- 
ically for  tuberculous  patients.  The  humidity  is  fairly — that  is,  mod- 
erateh^ — high,  and  is  increased  by  the  rainy  season  in  winter  and  by 
the  fogs  in  the  dry  summer  season. 

The  fog  formation  along  the  Pacific  coast  has  always  been  consid- 
ered peculiar,  and  is  especially  frequent  in  the  spring  and  summer 
within  40  miles  of  the  coast.  This  interferes  somewhat  with  the  amount 
of  sunshine,  although  the  high  fogs  usually  disappear  before  noon. 
The  weeks  that  occur  without  fogs  are  uncomfortably  warm,  and  occa- 
sionally there  is  a  hot,  dry  wind  from  the  northeast,  laden  with  fine 
dust.  On  the  whole,  the  climate  for  the  year  is  more  equable  and 
comfortable  than  other  coast  climates  in  the  United  States,  with  cool 
nights  throughout  the  year.  Thunderstorms  or  strong  winds  are  com- 
paratively rare  and  never  severe.  There  is  a  cooling  breeze  from  tht^ 
ocean  by  day,  and  from  the  mountains  by  night.  California  is  soothing, 
while  Colorado  is  stimulating  (Fisk,  '01).  The  indications  for  sending 
patients  to  this  region  are  those  given  under  Coast  Climates. 

Los  Angeles,  altitude  287  feet,  is  about  15  miles  from  the  coast,  and 
is  well  kno\vTi  as  the  metropolis  of  southern  California.  It  is  as  at- 
tractive as  any  city  of  like  size  in  the  western  country.  Its  population 
in  the  past  ten  years  has  more  than  doubled;  in  1007  it  was  280,000. 
It  is  well  supplied  with  all  the  attractions  and  comforts  of  a  modern  city. 


716  CLIMATIC  THERAPEITTICS 

Its  great  dovclopment  in  the  past  few  years  has  gradually  lessened  its 
desirahility  as  a  health  resort.  The  dust  and  dirt  have  inereased  with 
the  growing  industries.  Eastern  people,  once  visitors,  often  settle  per- 
manently. It  is  more  difficult  than  formerly  to  get  accommodations  for 
tuberculous  patients.  At  present  it  is  best  to  send  patients  to  the  foot- 
hill districts  and  the  sparsely  settled  inland  places,  where  the  humidity 
is  somewhat  less  and  the  air  free  from  dust  and  contamination.  Like 
Denver,  howcn^er,  a  person  I'ccovering  from  tuberculosis  near  this  region 
lias  the  advantage  of  being  able  to  enter  business  life. 

Pasadena,  altitude  800  feet,  is  nine  miles  northeast  of  Los  Angeles, 
and  more  suitable  for  winter  residence.  This  town,  too,  is  rapidly 
growing  out  of  the  resort  class,  but  its  outlying  districts  are  still  Avell 
adapted  for  open  resort  treatment.  It  is  one  of  the  most  charming 
residential  places  on  the  continent,  with  beautiful  homes  and  well-kept 
grounds.  Tuberculous  patients  who  come  to  southern  California  will, 
as  a  rule,  do  better  in  the  foothill  regions  of  Pasadena  and  the  San 
Gabriel  Valley,  up  to  and  including  Eiverside  and  Eedlands.  Places 
along  this  region  vary  from  800  feet  to  2,500  feet,  and  the  farther  away 
such  places  are  from  the  ocean  the  less  fog  and  the  more  heat. 

Suitable  places  are  AUadena,  Sicrm  Madrc,  Monroria,  Ontario,  San 
Bernardino,  and  Redlands.  The  fii-st  four  are  comfortable  throughout 
the  year,  with  some  hot  days  in  summer.  Altadena  and  Monrovia  are 
each  supplied  with  an  excellent  sanatorium.  Riverside,  San  Bernardino, 
and  Redlands  are  suitable  winter  resorts,  but  too  warm  in  summer.  Of 
all  these  places,  Redlands,  altitude  1,200  feet,  has  the  best  winter  cli- 
mate, with  good  accommodations  for  incipient  cases.  It  is  difficult  in 
any  California  resort  to  get  accommodations  for  advanced  patients.  The 
climatic  conditions  are  such  that  one  can  live  outdoors  with  comfort, 
day  and  night,  the  year  around,  and  l)e  comfortable  under  blankets 
every  night  of  summef. 

The  weather  statistics  of  Los  Angeles  (Henry,  '06)  will  serve  as  a 
guide  for  this  region.     (See  Table  XV.) 

San  Diego,  altitude  40  feet,  has  the  warmest  winter  and  coolest 
summer  of  any  town  in  southern  California.  The  humidity  is,  how- 
ever, higher  than  in  the  inland  regions,  though  the  mean  temperature, 
compared  with  Los  Angeles,  is  nearly  the  same.  The  absolute  minimum 
temperature  for  San  Diego  during  the  winter  is  32°  F. ;  for  Los  An- 
geles, 28°  F.,  and  the  absolute  maximum  for  San  Diego  in  summer 
is  94°  F. ;  for  Los  Angeles,  106°  F.  The  relative  humidity,  compared 
with  that  of  Los  Angeles,  is  high — 80  per  cent  a.m.  and  75  per  cent 
p.:\r.  This  difference  is  about  the  same  for  all  seasons,  though  the  rain- 
fall is  much.  less.  There  are  few  places  for  tuberculous  patients  in  San 
Diego,  and  one  had  best  make  arrangements  before  going.    The  country 


ENLMEKATION   OF   KESUKTS 


717 


TABLE    XV 
1877-1903 


TEMPKR.A.TURE 

Pkecipitation 

Mean 
hu.miditv 

(U 

1 

"q 

CIS 

h 

(2 

Los  Anueles, 

o 

M  = 

Cal 

"o.S 

j: 

^oS-S 

. 

- 

r^ 

c^ 

Altitude.  287  Feet 

g 

c 

55 

$5  JCS 

.>s 

.ti 

5i2 

1? 

l§ 

s 

5^ 

c  S 
IS 

a; 

5^^  = 

a>'3v 

i- 

s 

Q 

►-. 

tf 

s 

< 

Winter  Mean...  . 

55 

66 

45 

8.9 

18 

67 

64 

74 

N.  E. 

227 

Spring  Mean. .  .  . 

60 

70 

49 

4.3 

14 

83 

64 

66 

W. 

263 

Summer  Mean .  . 

70 

82 

58 

0.1 

1 

88 

62 

74 

w. 

319 

Fall  Mean 

65 

77 

52 

2.3 

6 

75 

65 

77 

w. 

263 

Annual  Mean. .  . 

62 

74 

51 

15.6 

40 

78 

64 

73 

w. 

268 

districts  back  of  San  Diego  are  attractive  climatically,  and  one  can  find 
mountain  places  (Julian)  up  to  5,000  feet,  but  they  are  too  primitive 
for  tuberculous  patients. 

Santa  Barbara,  altitude  1.30  feet,  has  much  the  same  weather  con- 
ditions as  San  Diego,  though  not  so  equable;  the  winters  are  slightly 
colder  and  the  summers  warmer.  There  are  often  severe  winds  from 
the  ocean,  and  altogether  the  place  is  inferior  to  San  Diego.  In  other 
wa3's,  however,  this  town  is  the  most  attractive  place  on  the  coast,  and 
gives  excellent  accommodations.  The  nearness  of  the  mountains  to 
the  ocean  makes  a  picture  unsurpassed  in  southern  California.  One  may 
live  at  Santa  Barbara,  near  the  ocean,  at  an  elevation  of  800  feet.  The 
disadvantages  are  the  fogs  and  winds.  There  are  places  in  the  foothills 
near  Santa  Barbara  (Ojai  Valley)  which  are  protected  and  more  suitable 
for  consumptives,  but  the  accommodations  are  poor  and  the  food  is  bad. 


FOREIGN    RESORTS 

Mexico. — From  a  climatic  standpoint,  the  mountain  regions  of 
Mexico  aie  more  suitable  for  lung  cases  than  southern  California.  The 
winters  are  dry,  mild,  and  agreeable,  with  much  sunshine.  In  the  ele- 
vated regions,  Mexico  City  (7,215  feet)  and  Guadalajara  (5,100  feet) 
are  the  two  places  most  suitable  for  Americans,  where,  on  account  of 
the  size  of  the  cities,  comforts  may  be  obtained.  Contrary  to  the  gen- 
eral impression,  the  summers  are  more  agreeable  than  the  winters. 

'I'he  chief  objections  are  the  trip  to  and  from  Mexico,  the  difTicully 
in  obtaining  suitable  accommodations  and  food,  and,  in  many  places, 
the  unsanitarv  surroundings. 


718  CLIMATIC  THERAl'El'TK'S 

Canada. — The  Canadian  Kockics  and  British  ColiuulMa  (Hinsdale, 
"02)  have  a  boldness  of  scenery  unsurpassed  in  this  country,  and  might 
be  said  to  resemble  the  Alps.  The  summers  are  cool,  dry,  and  bracing, 
and  the  region  has  the  advantages  of  a  mountain  climate,  but  is  too 
extreme  for  winter  residence.  Its  great  disadvantages  are  the  difficult 
transportation  and  no  winter  accommodations. 

In  Ontario  the  climate  is  influenced  by  the  Great  Lakes,  and  it  is 
cool  and  moist  through  the  summer;  the  winters,  though  intensely  cold, 
are  relatively  dry,  and  the  sharp  changes  met  with  in  the  United  States 
are  wanting. 

Gravenhurst  is  a  favorite  resort  for  the  tuberculous,  and  near  it  is 
situated  the  well-known  Muskoka  Cottage  Sanatorium,  altitude  800  feet, 
established  in  1897. 

Madeira,  an  island  350  miles  from  the  northwest  coast  of  Africa, 
long  considered  the  best  winter  place  for  tuberculosis,  is  an  example  of 
an  island  type  of  climate,  being  more  equable  and  drier  than  is  usual. 
It  is  no  longer  a  favorite  resort,  except  for  those  needing  such  a  sooth- 
ing, relaxing  atmosphere.  Its  great  charm  is  the  beauty  of  its  scenery, 
and  the  mild  climate,  free  from  winds  and  dust. 

Canary  Islands. — These  islands  are  200  miles  south  of  Madeira,  are 
warmer,  have  more  wind  and  dust,  but  otherwise  the  climate  is  similar 
to  Madeira. 

The  indications  for  all  these  coast  regions  are  those  given  previously 
under  Coast  Climates. 

Europe. — The  Alpine  region  has  acquired  the  greatest  reputation  for 
the  altitude  treatment  of  tuberculosis.  The  best  kno^vn  and  most  im- 
portant resorts  are  St.  Moritz  (altitude  6,000  feet),  Davos-Platz  (alti- 
tude 5,352  feet),  Arosa  (altitude  6,100  feet),  and  Leysin  (4,700  feet). 
St.  Moritz  (Klebs,  A.  C,  '06)  and  Davos  have  the  greatest  reputations, 
and  are  noted  for  their  stimulating  effects  and  general  attractiveness. 
Both  can  boast  of  fine,  pure  air,  great  dryness,  cold  winters  and  cool 
summers,  with  freedom  from  strong  winds  and  dust  storms.  Patients 
who  can  go  to  this  climate  make  the  greatest  gain  in  the  dry,  cold, 
stimulating  air  of  winter.  Indications  are  the  same  as  for  the  high 
altitudes  of  the  Eocky  Mountain  region. 

The  resorts  along  the  European  coast  are  so  numerous  that  space 
permits  but  brief  mention  of  a  few  of  the  better  known.  The  French 
and  Italian  Riviera  are  favorite  winter  resorts,  especially  for  English 
people.  They  are  protected  on  the  north  by  mountains,  and  the  air 
has  an  agreeable,  soothing  effect.  The  French  Eiviera  is  less  protected 
from  cold  wind  than  the  Italian  Eiviera.  The  contrast  of  the  blue  sea 
near  the  high  mountains  is  not  unlike  a  few  spots  on  the  California 
coast.     One  must  expect  rain  in  the  season — twenty-five  to  thirty  days— 


ENUMERATION    OF   KESORTS  719 

from  ^'ovemher  to  A})!'!!.  The  rain  ofli'U  comes  in  .sliowors,  leaving  llio 
skv  clear  and  blue.  Cannes,  Monte  Carlo,  and  ^Ice  are  most  expensive; 
the  social  life  and  amusements  are  too  great  temptations  for  those  seek- 
ing health.  Sice  is  the  largest  town,  and  less  attractive  than  Cannes. 
Mentone  is  warmer  in  winter,  better  protected  from  wind;  a  quiet, 
dull  place,  and  better  suited  for  patients.  Bordighera  and  San  Renio, 
on  the  Italian  Riviera,  have  the  same  advantages  for  the  invalid  as 
Men  lone,  but  are  more  attractive,  and  are  growing  in  fame  as  health 
resorts. 

Southern  Spain  has  several  resorts  climatically  similar  to  the  Kiviera; 
they  are  less  frequented,  but  some  find  them  more  agreeable. 

For  inland  climates  of  medium  altitudes,  suitable  for  consumptives 
both  winter  and  summer,  some  of  the  German  resorts  may  be  particu- 
larly mentioned,  these  places  having  gained  their  fame  largely  from 
the  excellent  sanatoria  established  there.  Of  such  resorts  may  be  men- 
tioned Goehersdorf  (altitude,  1,700  feet),  where  Brehmer  established  his 
sanatorium  in  1859;  Falkenstein,  which  his  pupil,  Dettweiler,  made 
famous;  Hohenhonnef  and  the  Black  Forest  region,  with  Walthers  col- 
ony at  Nordrach,  Wehrawald,  Selwmberg,  etc.  In  the  south  of  France 
are  to  be  found  Pan,  Biarritz,  and  others. 

Russia.— Iw  Russia,  a  good  winter  climate  is  found  in  Yalta,  on  the 
southern  coast  of  the  Crimea,  which  is  well  protected  by  hills  and  re- 
sembles the  climate  of  Madeira,  but  is  too  warm  in  summer.  For  tuber- 
culosis the  year  round  the  inland  climates  situated  in  the  Caucasus — 
Ahhas-Tuman  (altitude  3,505  feet)  and  Borjon,  with  excellent  hotel 
accommodations — are  popular. 

Africa. — In  this  country  two  regions  offer  advantages — Egypt  and 
South  Africa.  Egypt  offers  a  dry  and  equable  climate,  but  suitable 
only  in  the  winter  season — from  December  to  May.  The  region  from 
Cairo  to  Assouan  ofPers  the  best  accommodations.  Xear  Cairo  the  rain- 
fall is  very  slight  throughout  the  year.  In  lower  Egypt,  Helouan,  near 
Cairo,  is  a  desirable  resort.  In  upper  Egypt  are  Luxor  and  Assouan, 
the  latter  being  drier  and  more  healthful  than  the  Cairo  region,  and 
being  also  the  cleanest,  driest,  warmest  place  in  all  Egypt.  The  mos- 
quitoes and  flies  are  the  great  drawbacks  in  Egypt,  especially  in  the 
spring. 

South  Africa. — The  southeastern  coast  is  the  best  knowm  portion, 
April  to  October  corresponding  to  the  winter  or  rainy  season.  Resorts 
wliich  may  he  mentioned  are  Durhan  on  the  coast.  Cape  Town  and  the 
Transvaal  in  tln^  interior.  Johanneshur<i  (altitude  5,()8i)  feet)  and  Pre,- 
loria  (altilude  1,171  feet)  have  dryness,  but  dust  storms  are  not  inl're- 
(pient.  Many  of  the  j^laces  are  handicap])ed  by  bad  sanitary  conditions 
and  poor  accommodations  and  food. 


720  CLIMATIC  THERAPEUTICS 

ADDENDA 

Summarij  of  Climatic  Treatmetit  Presented  at  the  International  Con- 
gress, held  in  Washington,  D.  C. 

No  important  changes  in  climatic  therapeutics  Avere  introduced  or 
presented  in  the  papers  of  the  International  Congress  on  Tuberculosis. 
Much  of  the  ground  covered  in  the  previously  written  chapter  on  Prac- 
tical Climatic  Therapeutics  was  given  and  discussed  in  various  ways, 
with  no  different  results  than  those  already  shown.  A  few  whose  time 
was  devoted  to  the  effects  of  climate — men  such  as  Knight,  of  Boston, 
and  Williams,  of  London — advocated  climatic  treatment  by  change  of 
climate  under  proper  conditions.  The  great  benefit  derived  from  change 
of  scene  and  surroundings  is  part  of  climatic  treatment.  Again,  it  was 
noted  that  there  is  no  specific  climate,  and  the  keynote  was  struck  in 
saying  that  each  case  should  be  a  law  unto  itself,  always  to  individualize 
— that  is,  to  obtain  for  each  case  the  best  climate  available.  In  the 
modern  treatment  of  tuberculosis,  whether  a  patient  is  home  or  abroad, 
and  whatever  the  meteorological  conditions  may  be,  climatic  treatment 
is  an  important  therapeutic  agent.  The  majority  of  the  members  agreed 
that  most  patients  do  better  away  from  home,  uninfluenced  by  home 
surroundings  and  the  kind  but  usually  7nisdirectcd  advice  of  the  family. 
Especially  was  this  em])hasized  by  Minor,  of  Asheville.  In  choosing  a 
suitable  climatic  place,  the  nonclimatic  factors  must  be  considered; 
whether  the  patient  should  have  sanatorium  or  home  treatment  depends 
much  upon  the  individual  and  the  medical  attendance  obtainable. 

Carrington,  of  Xew  Mexico,  showed  that  while  the  southwestern 
localities  have  some  provision  for  the  care  of  the  tuberculous,  few  have 
adequate  provision,  and  practically  no  charitable  institutions.  He  cau- 
tioned physicians  against  sending  indigent  consumptives  to  the  southwest. 

In  the  true  climatic  sense,  the  high-altitude  treatment  received  great 
impetus  from  this  Congress,  as  accomplishing  the  greatest  good  for  the 
largest  number.  At  high  altitudes  the  great  number  of  clear,  bright 
days  through  the  year,  even  in  the  winter  time,  was  emphasized,  as  well 
as  other  advantages  previously  enumerated  by  the  writer.  The  high- 
altitude  treatment  is  most  successful  in  early  cases  and  those  with 
consolidation.  It  stimulates  the  whole  system,  lessens  the  clinical  symp- 
toms, and  brings  an  increase  in  weight.  In  speaking  on  altitude, 
Williams  said  that  climatic  treatment  of  itself,  Avithout  hygiene,  was 
known  to  be  the  cause  of  recovery,  especially  in  the  instances  of  patients 
living  in  high  altitudes  of  the  Andes  and  Alps.  It  was  urged  that  the 
tendency  to  hemorrhage  is  no  contraindication  for  high  altitude,  except 
when  due  to  increased  blood-pressure;  nor  is  fever  a  contraindication, 
except  in  eases  of  rapid  pulse  and  heart  action. 


PART  VI 
SURGICAL  TUBERCULOSIS 


CHAPTER   I 

TUBEECUL0SI8    OF    THP]    LYMPH    GLAXDS 
By  LEONARD  FREEMAN 

This  form  of  tuberculosis  is  often  regarded  as  conservative,  because 
the  arrest  of  tubercle  bacilli  in  the  lymph  nodes  may  prevent  their 
penetration  to  more  important  parts.  Although  nodes  in  almost  any 
portion  of  the  body  can  become  affected,  the  disease  usually  appears  in 
certain  definite  regions,  such  as  the  neck,  groin,  axilla,  mediastina,  and 
abdomen.  The  trouble  nearly  always  arises  from  some  neighboring  focus 
with  which  the  nodes  are  in  immediate  relation,  although  cases  are 
occasionally  seen  in  which  infection  seems  to  have  traveled  through  the 
blood  from  a  distant  part.  It  should  be  noted  that  the  primary  focus 
may  be  comparatively  trivial  while  the  glandular  involvement  is  ex- 
tensive. 

Section  of  a  diseased  node  generally  reveals  nodules  of  some  size 
which  are  formed  from  a  conglomeration  of  smaller  tubercles,  and  are 
often  caseous  (Plate  III).  Softening  of  these  caseous  areas  is  common, 
and  the  entire  gland  may  thus  be  transformed  into  a  tuberculous  ab- 
scess confined  within  the  more  or  less  dilated  and  thickened  capsule. 
Occasionally  calcification  or  the  development  of  fibrous  tissue  may  lead 
to  an  arrest  of  the  process.  It  is  claimed  that  in  rare  instances  hyper- 
plasia of  the  nodes  occurs  without  the  development  of  definite  tul)ercles, 
producing  a  condition  closely  resembling  Hodgkin's  disease.  There  are 
even  those  who  regard  Hodgkin's  disease  as  a  manifestation  of  glandu- 
lar tuberculosis,  but  this  view  is  not  generally  accepted. 

As  the  trouble  progresses  the  glands  increase  in  size,  often  becoming 
as  large  as  walnuts.  There  is  a  tendency  toward  progressive  infection 
of  neighboring  nodes  in  the  direction  of  lymphatic  circulation,  which 
may  lead  to  the  involvement  of  an  entire  region — for  instance,  the 
cervical  or  the  inguinal.  If  the  glandular  capsule  gives  way,  tubercu- 
lous periadenitis  results,  implicating  the  surrounding  connective  tissue 
and  causing  extensive  adhesions  to  adjacent  structures,  such  as  blood- 
vessels, nerves,  and  muscles.  This  process  is  sometimes  so  extensive  as 
to  produce  large  indurated  areas,  in  which  are  embedded  numerous 
caseous  and  purulent  glands. 

723 


724  TUBERCULOSIS  OF  THE  LYMPH   GLANDS 

Involvement  of  the  skin  is  frequent,  as  is  also  the  formation  of 
sinuses,  through  which  are  discharged  the  contents  of  nodes.  The  skin 
presents  a  dark  red  or  livid  hue,  and  when  it  breaks  down,  as  it  is 
apt  to  do  about  the  mouth  of  a  sinus,  the  edges  of  the  resulting  indo- 
lent ulcer  are  undermined  and  ragged.  If  healing  occurs,  a  white, 
puckered,  and  disfiguring  scar  remains,  as  is  so  often  seen  about  the 
neck.  The  sinuses  leading  to  tuberculous  glands  are  notoriously  chronic 
and  hard  to  cure. 

Although  the  lymph  channels  leading  from  one  gland  to  another  are 
often  tuberculous,  this  is  usually  lost  sight  of  in  the  general  involvement 
of  the  tissues.  Barely  the  cutaneous  lymphatics  become  diseased,  espe- 
cially those  of  the  forearm,  following  tuberculous  infections  of  the  fin- 
gers (so-called  anatomic  tubercles).  Caseous  nodules  then  result,  dis- 
tributed along  the  course  of  the  lymphatics,  which  may  break  down  and 
cause  ulcerations  of  the  skin. 

The  presence  of  the  tuberculous  virus  can  always  be  demonstrated 
by  animal  inoculation,  but  it  is  generally  difficult  and  sometimes  im- 
possible to  find  the  tubercle  bacillus  with  the  microscope;  hence  the 
failure  to  do  this  should  not  be  given  too  much  weight  in  the  diagnosis. 
The  tuberculin  test  is  fairly  conclusive,  providing  a  focus  of  disease 
does  not  exist  elsewhere,  which,  however,  cannot  always  be  determined 
with  certainty. 

Tuberculous  lymph  glands  are  liable  to  mixed  infection,  especially 
with  the  ordinary  pus-forming  microorganisms,  which  often  leads 
to  inflammatory  swelling,  accompanied  by  pain,  tenderness,  and  the 
general  symptoms  of  sepsis,  thus  obscuring  the  real  origin  of  the 
trouble. 

Etiology. — Most  cases  of  tuberculous  adenitis,  particularly  the  cervi- 
cal form,  develop  in  the  young  under  bad  h3'gienic  surroundings — in 
the  slums,  tenements,  and  sweatshops  of  large  cities,  and  wherever 
people  are  overcrowded,  overworked,  and  underfed,  with  lack  of  sleep, 
fresh  air,  and  sunshine — but  this  is  not  always  the  case,  as  the  disease 
is  frequently  enough  met  with  in  children  reared  under  the  best  possible 
conditions.  A  weak  resisting  power  may  also  be  due  to  heredity  or 
brought  about  by  one  of  the  acute  infectious  diseases,  especially  measles 
or  scarlet  fever.  Occasionally  infection  occurs  through  a  wound  of  the 
hand  or  foot,  giving  rise  to  corresponding  trouble  in  the  lymph  glands 
of  the  axilla  or  groin  (the  writer  has  seen  extensive  tuberculosis  of  the 
inguinal  glands  in  an  infant  resulting  from  a  slight  prick  of  the  thigh 
with  a  safety-pin).  Lymphatic  absorption  of  bacilli  from  the  uninjured 
intestinal  and  bronchial  surfaces  is  perhaps  not  uncommon,  thus  ac- 
counting for  obscure  cases  of  tuberculosis  of  the  mesenteric,  bronchial, 
and  other  glands. 


SYMPTOMS  AND   DIAGNOSIS  725 

Symptoms  and  Diagnosis. — Tuberculous  adonilis  almost  always  de- 
velops slowly  and  painlessly  during  the  course  of  weeks,  months,  or 
even  years,  unless  mixed  infection  is  present;  this  chronicity  and  com- 
parative absence  of  active  s}inptoms  is  of  much  importance  in  the  diag- 
nosis. In  rare  instances,  however,  the  affected,  glands  may  enlarge 
rapidly,  and  Avith  more  or  less  pain  and  rise  of  temjierature.  A  mod- 
erate glandular  enlargement  is  not  incompatible  witli  good  health  in 
other  respects,  but  if  the  disease  is  marked,  the  general  nutrition  is  apt 
to  suffer.  Anemia  is  often  present,  with  loss  of  appetite,  flesh,  and 
energy.  Sometimes  the  flesh  is  retained,  but  the  skin  has  a  more  or 
less  "  pasty  "  and  unhealthy  appearance.  These  several  conditions,  to- 
gether with  the  enlarged  glands  and  a  tendency  to  eczema  and  catarrhal 
affections  of  the  mucous  membranes,  constitute  what  was  formerly  desig- 
nated as  the  "  scrofulous  diathesis,"  but  is  now  regarded  as  being  due 
to  absorption  of  tuberculous  virus.  The  enlargement  of  the  lymph  glands 
may  cease  at  any  time,  become  latent  for  a  longer  or  shorter  period,  or 
disappear  altogether,  the  course  pursued  depending  largely  on  the  con- 
dition of  the  resisting  powers  of  the  patient ;  but  the  usual  course  is  a 
continuous  increase  in  size,  accompanied  by  infection  of  neighboring 
glands,  frequently  terminating  in  periadenitis  and  the  formation  of  ab- 
scesses and  fistula?.  Death  seldom  results,  although  it  may  occur  from 
sepsis,  exhaustion,  or  amyloid  changes;  but  extensive  disfigurement  is 
not  uncommon,  from  unsightly  scars  and  swelMngs,  especially  about  the 
neck.  There  is  considerable  danger  of  tuberculosis  appearing  elsewhere 
— for  instance,  in  the  lungs — which  is  a  strong  argument  in  favor  of 
early  and  energetic  treatment. 

In  forming  a  diagnosis,  the  chronicity  of  the  disease,  together 
with  the  absence  of  inflammatory  symptoms,  usually  serves  to  distin- 
guish it  from  acute  adenitis.  Mixed  infection  may  lead  to  con- 
fusion; but  if  enlargement  of  the  nodes  persists  after  the  acute 
manifestations  have  subsided,  tuberculosis  should  be  suspected,  espe- 
cially following  an  infectious  disease  in  childhood.  In  fact,  any 
chronic  glandular  enlargement  in  a  child  should  be  looked  on  as  be- 
ing tuberculous  unless  it  can  be  demonstrated  to  be  from  some  other 
cause. 

Differentiation  from  HodgHns  disease  or  malignant  lymphoma  is 
often  difficult,  and  mistakes  are  frequently  made.  Tuberculous  glands, 
however,  usually  develop  more  slowly  without  reaching  so  large  a  size. 
They  are  harder  at  all  times  unless  abscesses  form,  and  if  numerous  and 
of  considerable  size,  when  confusion  is  most  likely  to  result,  they  are, 
as  a  rule,  immovable  from  periadenitis.  Sinuses  are  also  apt  to  exist, 
together  with  involvement  of  the  skin.  In  Hodgkin's  disease,  on  the 
contrary,   the   glands   enlarge  extensively   and   rapidly,   and   are   soft. 


726  TUBERCULOSIS  OF   TPIE   LYMPH   GLANDS 

sniootli,  movable,  and  easily  outlined,  without  the  matting  together 
which  is  so  characteristic  of  tuberculosis. 

Cysts  and  other  tumors  can  usually'  Ix-  recognized  b}^  attention  to 
the  family  and  personal  history  and  to  local  appearances,  the  use  of 
tuberculin  in  the  diagnosis  being  seldom  required.  Syphilis  is  recog- 
nized by  the  history,  the  acuteness  of  the  glandular  enlargement,  the 
juH^sence  of  other  specific  lesions,  and  the  absence  of  sinuses,  skin  in- 
volvement, etc. 

Treatment. — This  is  both  general  and  local,  the. latter  being  divided 
into  nonoperative  and  o])erative. 

General  Treatment. — This  is  always  indicated,  either  for  its  curative 
effect  in  early  stages  or  as  a  safeguard  against  relapse  following  oper- 
ation. 

Hygienic  measures  are  of  the  utmost  importance — good  food,  plenty 
of  air  and  sunshine,  and  appropriate  exercise.  It  lias  long  been  ob- 
served that  patients  do  remarkably  well  at  seaside  resorts,  and  it  is 
beginning  to  be  recognized  that  residence  in  a  dry  climate,  at  a  high 
altitude  (in  Colorado,  for  instance),  is  even  of  greater  service. 

Medicines  accomplish  but  little,  as  a  rule.  Those  most  in  use  are 
the  sirup  of  the  iodid  of  iron,  the  hypophosphites,  creosote,  and  guaia- 
col.  The  vaccine  therapy  of  Wright  is  still  on  trial,  and  it  can  be 
said  that  encouraging  results  have  been  obtained.  The  size  and  fre- 
quency of  the  doses  of  tuberculin  are  determined  by  noting  the  opsonic 
index  of  the  patient.  So-called  specifics,  such  as  cinnamic  acid,  although 
highly  recommended  by  some,  have  not  come  into  extensive  use.  In 
fact,  the  question  of  medication  seems,  at  the  present  time,  to  consist 
more  in  building  up  the  resisting  powers  of  the  patient  than  in  attempt- 
ing to  kill  the  germs  of  the  disease  with  specific  drugs. 

Local  Treatment. — Massage,  and  crushing  the  nodes  between  the 
fingers,  or  their  subcutaneous  division  with  a  tenotome,  are  all  danger- 
ous and  ineffective  methods,  favoring  both  local  and  general  dissemina- 
tion. Passive  hyperemia  (Bier)  may  be  tried  in  suitable  cases,  although 
in  the  neck,  groin,  and  axilla  the  effective  application  of  the  constricting 
band  is  rather  difficult. 

Ointments  and  counter-irritants  are  of  doubtful  utility,  although 
extensively  employed.  Among  the  former  may  be  mentioned  ichthyol, 
resorcin,  and  the  iodid  of  lead,  and  among  the  latter  tincture  of 
iodin  and  green  soap.  Troganow  places  a  hot-water  bag  on  the  nodes 
for  an  hour  or  two  each  day,  claiming  much  benefit  from  its  employ- 
ment. The  X-ray  is  occasionally  of  service,  especially  in  incipient 
cases. 

Injections  into  the  glands  have  long  been  employed.  Some  sub- 
stances are  used  for  their  direct  curative  effects,  such  as  tincture  of 


TREATMENT  727 

iodin  (.")  to  10  drops  every  four  days)  ;  Fowler's  solution,  in  increasing 
doses  (8-10-1:2  drops)  ;  solutions  of  carbolic  acid,  acetic  acid,  nitrate 
of  silver,  corrosive  sublimate,  gua.iacol,  phospbate  of  iron,  etc.  Other 
materials,  such  as  chlorid  of  zinc  (two  to  ten  per  cent),  stronger  solu- 
tions of  carbolic  acid,  papain,  etc.,  are  used,  to  cause  rapid  liquefac- 
tion of  the  glands.  The  method  of  Calot,  for  instance,  is  to  inject 
t\vo-])or-cont  chlorid  of  zinc  every  other  day,  until  purulent  softening 
occurs,  wlien  tbe  fluid  is  aspirated  and  replaced  with  camphorated 
na])hthol. 

These  procedures,  although  they  have  been  strongly  advocated,  are 
often  disappointing,  and  are  not  free  from  discomfort  and  even  danger, 
as  evidenced  by  cases  of  poisoning  from  camphorated  naphthol.  If  in- 
jections are  used,  the  best  is  probably  ten-per-cent  iodoform  in  olive 
oil,  which  must  be  sterilized  carefully.  Into  nodes  which  have  not  yet 
broken  down,  about  half  a  hypodermic  syringeful  is  inserted  every  eight 
to  ten  days,  while  glands  containing  pus  are  aspirated  and  filled  with 
the  material. 

In  estimating  the  value  of  the  injection  treatment  it  must  not  be 
overlooked  that,  although  certain  ghmds  may  disappear,  there  are 
often  others  which  cannot  be  reached  or  even  recognized  without  a 
surgical  operation,  and  which  are  apt  to  give  rise  to  trouble  in  the 
future. 

Operative  Treatment. — This  is  indicated  in  most  cases,  the  presence 
of  pulmonary  tuberculosis  being  no  contraindication  to  operation  unless 
quite  advanced,  as  improvement  often  occurs  after  the  removal  of  the 
nodes. 

Curettement  is  principall}''  applicable  to  sinuses,  the  results  being 
good  where  it  is  possible  to  reach  all  diseased  material  in  the  under- 
lying glands.  The  infected  skin  around  the  opening  of  the  sinus  must 
also  be  removed.  Cauterization  with  chemicals,  such  as  ninety-five-per- 
cent carbolic  acid,  is  occasionally  of  service.  Tuberculous  sinuses  may 
often  be  treated  successfully  by  suction,  according  to  Bier's  method. 
A  small  cupping  glass,  provided  with  a  rubber  bulb,  is  placed  over  the 
sinus,  and  by  means  of  pressure  on  the  bulb  the  air  is  exhausted  to  an 
extent  sufficient  to  cause  marked  hyperemia.  This  empties  the  sinus 
and  may  produce  some  capillary  bleeding,  which  is  beneficial  rather  than 
otherwise.  The  procedure  is  carried  out  daily,  each  sitting  lasting  about 
three  quarters  of  an  hour,  with  the  cup  in  place  a  few  minutes  and  then 
removed  a  few  minutes  during  this  time.  When  the  discharge  becomes 
watery  the  intervals  between  the  cuppings  are  lengthened. 

Extirpation  of  tuberculous  lymph  glands,  when  possible,  ofi'ers  a 
better  chance  for  permanent  recovery  than  any  other  procedure,  but  the 
operation  must  be  thorough  or  relapses  will  supervene. 


728  TUBERCULOSIS   OF   THE   LYMPH   GLANDS 

TUBERCULOSIS   OF   THE   CERVICAL   LYMPH   GLANDS 

There  are  several  hundred  lymph  gland. s  in  the  neck,  some  of  them 
superficial  and  others  deep.  They  exist  principally  in  definite  groups, 
which  are  usually  infected  from  the  tonsils,  teeth,  and  pharynx.  Tu- 
herele  hacilli  may  also  gain  entrance  from  a  chronic  otitis,  eczema 
of  the  scalp,  ophthalmia,  or  various  nasal  troubles,  or  tlioy  may  he 
deposited  from  the  l)lood  or  ascend  from  the  bronchial  lymphatics.  The 
nodes  most  frequently  involved  are  those  in  the  submaxillary  region  and 
those  lying  along  the  jugular  vein.  The  submental  and  parotid  regions 
are  at  times  implicated,  as  well  as  the  regions  about  the  mastoid  and 
above  the  clavicle. 

Often  the  disease  appears  on  one  side  only,  but  occasionally  the  en- 
tire neck  is  involved,  giving  rise  to  great  disfigurement.  It  has  been 
estimated  that  pulmonary  and  other  infections  follow  tuberculosis  of 
the  cervical  lymph  glands  in  more  than  twenty-five  per  cent  of  tlie 
cases,  a  serious  danger  wliich  should  not  be  underestimated. 

Whatever  form  of  treatment  is  selected,  it  is  of  prime  importance 
to  abolish,  if  possil)le,  the  original  source  of  infection  by  attention  to 
teeth,  tonsils,  pharynx,  and  nose,  and  by  the  eradication  of  inflam- 
mations of  the  ears  and  scalp.  The  importance  of  this  is  emphasized 
by  Goodale,  who  insists  that  many  enlarged  lymph  glands  can  be  re- 
duced merely  by  treating  the  tonsils  with  solutions  of  iodin. 

The  most  satisfactory  and  lasting  results  are  obtained  l)y  extirpation 
of  the  nodes,  unless  the  vaccine  therapy  of  Wright  proves  to  be  of 
greater  service  than  can  at  present  he  predicted.  Such  operations  vary 
from  the  easy  excision  of  a  single  gland  to  procedures  which  are  among 
the  most  difficult  in  surgery  owing  to  the  number  of  the  nodes  and  their 
relations  to  important  nerves  and  vessels ;  but  in  spite  of  this,  every 
diseased  gland  and  tissue  should  be  removed  or  relapse  will  promptly 
appear. 

The  skin  incision  should  be  planned  to  suit  the  individual  case, 
following  natural  folds  and  coneealing  scars  as  much  as  is  consistent 
with  thoroughness  and  safety ;  but  no  greater  surgical  indiscretion  can 
be  committed  than  to  attempt  to  remove  a  mass  of  enlarged,  matted, 
and  adherent  nodes  through  too  small  an  opening.  Bollinger's  incision, 
for  instance,  which  is  located  entirely  within  the  hair  back  of  the  ear, 
is  generally  inadequate  from  the  standpoint  of  thoroughness  and  safety. 
It  should  always  be  borne  in  mind  that  several  transverse  scars  may  be 
less  objectionable  than  one  longitudinal  scar,  because  they  are  less  liable 
to  stretch  or  become  hypertrophied  into  the  red,  raised,  and  unsightly 
cords  which  are  often  seen  following  cervical  operations.  Subcutaneous 
sutures  should  be  used  when  possible. 


INFECTION   OF   GLANDS   OF   GROIN  729 

Theoretically  it  is  best  to  remove  in  one  mass  all  the  lymphatic  struc- 
tures, and  the  connective  tissue  in  which  they  are  embedded,  Ijut  prac- 
tically this  is  not  always  possible,  and  the  operator  must  be  content 
with  the  enucleation  of  the  glands  alone,  which  fortunately  is  usually 
sutiicient.     It  is  seldom  necessary  to  divide  the  sternomastoid  muscle. 

Although  injury  to  the  internal  jugular  vein  is  not  frequent,  it  is 
nevertheless  wise  to  expose  it  early  in  the  operation,  if  possible,  being 
ready  for  compression  or  ligation,  if  necessary. 

Constant  vigilance  is  necessary  to  avoid  injury  to  various  nerves, 
the  most  important  of  which  are  the  spinal  accessory,  pneumogastric, 
phrenic,  laryngeal,  sympathetic,  and  facial,  especially  as  they  may  be 
forced  from  their  normal  positions  by  enlarging  glands  and  inflamma- 
tory tissues.  Division  of  the  phrenic  nerve  is  a  serious  accident,  but  the 
pneumogastric  or  sympathetic  may  be  cut  without  disaster  following. 
The  facial  and  recurrent  laryngeal  nerves  must  he  avoided  with  the 
greatest  care,  owing  to  the  unfortunate  results  following  their  injury. 
The  possibility  of  penetrating  the  pleura  or  of  opening  the  thoracic 
duct  should  also  be  borne  in  mind. 

Anesthetic  areas  of  skin — for  instance,  about  the  ear — due  to  inter- 
ference with  cutaneous  nerves,  are  apt  to  cause  some  annoyance,  but 
fortunately  they  tend  to  disappear  in  time.  Temporary-  drainage  of 
the  wound,  combined  with  moderate  pressure  of  the  dressings,  will 
prevent  the  accumulation  of  blood  and  serum,  which  might  lead  to 
infection. 

It  is  difficult  to  estimate  the  number  of  complete  and  permanent 
cures  following  radical  operations.  Wohlgemuth  claims  70  per  cent, 
Hobel  68  per  cent,  and  Van  Noorden  62.4  per  cent,  an  average  of  65 
per  cent  in  309  cases,  while  Bios  estimates  the  number  at  46  per  cent 
and  Billroth  at  but  24  per  cent.  From  these  figures  it  is  seen  that 
repeated  operations  are  sometimes  necessary,  owing  to  the  occurrence 
of  relapses.  The  prognosis  is  generally  admitted  to  be  more  favorable 
in  children  than  in  adults. 


TUBERCULOUS  INFECTION  OF  THE  LYMPH  GLANDS  OF 

THE    GROIN 

This  form  of  tuberculosis  is  more  frequent  than  is  generally  recog- 
nized, although  it  is  far  from  common.  It  is  usually  mistaken  for  a 
complication  of  some  venereal  disease,  at  least  until  its  stubbornness 
and  chronicity  arouse  a  suspicion  of  tuberculosis.  'l'lu>  source  of  infec- 
tion may  be  somewhere  on  the  lower  extremity — about  the  genitalia, 
around  the  anus,  or  within  the  pelvis — Imt  quite  frequently  no  original 
focus  can  be  detected.     Tlic  disease   may  attack   both  deep  and  super- 


730  TUBERCULOSIS  OF   THE   LYMPH    (iLANDS 

ficial  glands  and  exliibits  a  marked  tendency  to  spread  upward  tlirougli 
the  lymphatic  structures  surrounding  the  iliac  vessels. 

As  in  tuberculosis  elsewhere,  operative  intervention,  in  order  to  be 
of  service,  must  be  thorough,  which  often  means  a  large  opening  and 
an  extensive  and  difficult  dissection.  In  order  to  follow  the  disease 
into  the  pelvis,  an  incision  must  be  made  extending  from  the  spine 
of  the  pubes  to  well  beyond  the  anterior  superior  spinous  process  of 
the  ilium,  with  division  of  Poupart's  ligament  near  its  internal  end. 
The  unopened  peritoneum  can  then  he  retracted  upward,  exposing  the 
vessels  and  the  glands  surrounding  them  as  far  as  the  bifurcation  of 
the  aorta,  if  necessary  (Lennander).  The  patient  should  be  warned 
that  a  species  of  elephantiasis  of  the  lower  extremity  and  genitalia  may 
follow  an  operation  in  which  all  the  inguinal  lymphatics  have  been 
removed,  although  such  an  unfortunate  complication  is  uncommon. 

TUBERCULOSIS  OF  LYMPH  NODES  IN  THE  AXILLARY  REGION 

These  glands  may  become  enlarged  in  connection  with  those  of  the 
neck,  or  the  focus  of  infection  may  be  situated  on  the  fingers — an  "ana- 
tomic tubercle,"  for  instance — or  in  the  mammary  gland. 

Extensive  and  careful  operations  are  necessary,  which  must  be  car- 
ried out  with  due  reference  to  the  large  vessels  and  nerves  of  the  part. 
The  incision  should  be  sufficiently  large,  and  not  pass  through  the 
axilla  itself,  but  above  the  anterior  axillary  fold,  as  in  carcinoma  of 
the  breast,  in  order  to  avoid  embarrassment  of  shoulder  motion  arising 
from  hypertrophy  and  contraction  of  the  scar. 


CHAPTER   II 

TUBERCULOSIS    OF    BONES    AND    JOINTS 
By  L.  L.  McARTHUR 

TUBERCULOSIS    OF    BONES 

Tuberculosis  invading  bony  structures  differs  in  no  wise  from  tu- 
berculosis in  otber  parts  of  the  body  except  in  so  far  as  the  histologic 
structure  of  the  tissue  influences  the  growth  or  is  influenced  thereby. 
It  seems  unnecessary  to  repeat  what  has  already  been  said  elsewhere  in 
this  volume  of  the  microscopic  patholog}',  or  to  enter  into  a  discussion 
of  it,  and  therefore  attention  will  be  directed  to  practical  factors  met 
clinically. 

It  is  now  universally  accepted  that  there  can  l)e  no  tuberculosis 
without  the  bacillus  of  Koch.  A  definite  understanding  as  to  the 
manner  in  which  infection  occurs  will  serve  to  make  clear  many  other- 
wise obscure  points  in  this  disease.  Infection  occurs  only  through 
the  circulation.  Many  writers  speak  of  primary  bone  and  joint  tu- 
berculosis. This  must  not  be  understood  m  the  sense  of  entire  ab- 
sence of  other  foci  in  the  individual,  since  postmortem  examinations 
reveal  other  discoverable  foci  in  seventy-nine  per  cent  of  the  cases 
(Koenig).  In  the  remaining  cases  (twenty-one  per  cent)  no  other 
focus  could  be  found.  It  has  been  proved  ex))erimentally  and  clin- 
ically that  the  bacillus  can  pass  through  the  intestinal  mucosa  with- 
out discoverable  lesion,  thus  gaining  access  to  the  mesenteric  lymph 
stream,  and  then  to  the  general  circulation.  Clinically,  therefore,  it  is 
pro])er  to  consider  a  bone  or  a  joint  tuberculosis  as  a  single  manifesta- 
tion (often  a  metastasis)  of  a  multiple  infection,  and  hence  attention 
must  be  given  to  the  general  as  well  as  the  local  treatment  of  the 
disease. 

Joint  or  bone  tuberculosis  presupposes  that  the  bacilli  are  floating 
in  the  blood  stream,  or  leucocytes  containing  them.  That  such  is  the 
case  has  been  demonstrated  <'xj)erimentally,  clinically,  and  pathologically. 
Su(,'h  floating  oi-ganisms  become  arrested  in  the  bones  or  joint  imder 
two  diflcicut  conditions:  (1)  In  the  arterioles;  (2)  in  the  ')lunt  venous 
terminals. 

731 


732  TUBERCUI.OSIS  OF   BONES  AND  JOINTS 

In  the  Arterioles. — Under  certain  conditions — as,  for  example,  a 
liquefying  lymph  gland — a  clump  of  organisms  gains  access  to  the  cir- 
culation, and  later  lodges  in  a  hone  arteriole,  wholly  or  partially  plug- 
ging it  and  producing  an  infarct  in  the  area  heyond.  This  infarct 
usually  is  wedge  or  cone  shape,  the  base  of  the  cone  being  directed 
toward  the  articular  surface. 

As  this  is  a  bacterial  embolus,  and  the  newly  formed  hemorrhagic 
infarct  is  an  excellent  culture  medium,  the  latter  becomes  tuberculous 
and  constitutes  a  common  type  of  focus  seen  in  bone.  Anatomically 
this  is  peculiarly  true  of  the  arterial  terminal  twigs  which  nourish  the 
articular  ends  of  long  bones,  thus  determining  the  shape  of  foci  occur- 
ring here.  Such  foci,  as  a  rule,  undergo  the  characteristic  degenera- 
tions of  tuberculous  tissue  elsewhere.  They  may  become  surrounded 
by  granulation  tissue,  itself  tuberculous,  thus  constituting  a  tuberculous 
sequestrum.  These  sequestra  are  never  so  sharply  defined  as  are  the 
sequestra  of  an  acute  osteomyelitis,  but  can  occasionally  be  lifted  out 
en  masse.  Karely  such  an  infarct  may  become  inclosed  by  a  capsule 
of  ivorylike  hai-dness — the  eburnated  infarct. 

In  Venous  Terminals. — There  is  to  be  seen  in  the  vascular  distri- 
bution to  the  epiphyseal  cartilage  of  bone  a  condition  scarcely  found 
in  any  other  part  of  the  body,  that  of  the  termination  of  the  blood- 
vessels in  blind  cul-de-sacs,  these  pouches  resting  with  their  blunt  ex- 
tremities directly  against  the  cartilage.  It  is  easily  understood  how 
the  sluggishness  of  the  circulation  in  such  a  blood-vessel  as  this  might 
favor  the  lodgment  and  growth  of  siich  infective  elements.  Clinically 
this  is  just  what  is  observed;  the  majority  of  tuberculous  bone  foci 
occur  in  close  proximity  to,  and  usually  on  the  joint  side  of,  the  epi- 
physeal cartilage.  Only  rarely  do  Ave  find  the  tuberculous  process  involv- 
ing primarily  the  shaft.  When  this  does  occur  it  forms  the  so-called 
tuberculous  osteomyelitis  (osteitis  sicca  tuberculosa) ;  it  is  usually  pro- 
gressive in  character,  and  of  serious  prognosis. 

The  infective  elements  having  gained  lodgment  in  the  manner  de- 
scribed, the  characteristic  tubercles  soon  form.  Occurring  in  bony  struc- 
ture, however,  they  induce,  probably  by  pressure,  a  calcareous  absorption. 
Just  as  a  varicose  vein  may,  by  pressure,  groove  the  tibia,  so  the  tuber- 
cular granulations  in  their  growth  dilate  the  cavities  in  which  they  lie, 
until  the  bony  lamellae  which  comprise  them  are  partly  or  wholly  ab- 
sorbed, with  a  resulting  osteoporosis,  often  demonstrable  by  the  X-ray. 
The  bone  is  replaced  by  tuberculous  tissue  which,  when  degenerated, 
seeks  an  exit.  The  caseous  material  escapes  in  the  form  of  a  granu- 
lar semifluid  detritus  along  the  lines  of  least  resistance.  If  the  tuber- 
cle is  transformed  into  fibrous  or  calcareous  material,  it  then  may  be- 
come encapsulated,  lying  dormant  until  a  trauma  excites  renewed  activ- 


TUBERCl'LOSIS   OF   BONES  7.S3 

ity.  It  i.s  almost  incredible  liow  Inug  the  local  process  may  remain 
quiescent. 

It  is  probable  that  in  every  case  of  bone  tuberculosis  there  exist 
other  etiologic  factors  than  the  tubercle  bacillus.  Trauma  is  the  most 
Important,  and  it  may  occur  in  the  form  of  heat,  cold,  and  also  toxins, 
or  even  other  infective  processes.  The  young  articular  ends  of  bones 
are  more  easily  traumatized  than  is  the  shaft ;  hence  the  frequency  with 
which  tuberculosis  localizes  there  in  the  young. 

Sometimes  the  granular  detritus  makes  its  way  into  a  neighboring 
joint,  or  it  passes  out  through  the  bony  lamella  to  the  surface  in  close 
proximity  to  the  joint.  If,  in  the  latter  case,  surgical  measures  are 
resorted  to  promptly,  the  joint  may  be  saved  from  infection  and  neces- 
sary incision  and  drainage. 

^^hen  the  contents  of  the  tuberculous  abscess  escape  into  the  adja- 
cent soft  parts,  a  so-called  cold  abscess  forms.  Unlike  abscesses  pro- 
duced by  acute  infective  agents,  it  is  extremely  slow  in  formation  and 
slow  in  perforating  the  skin  (since  the  tubercle  bacillus  induces  no  such 
cytolytic  action  as  do  the  acute  intlammatory  organisms).  The  con- 
tents of  the  abscess  consist  of  a  few  leucocytes,  many  fat  granules,  fine 
bone  fragments,  the  so-called  "  caseous  matter,"  albumin,  and  other 
products  of  degeneration.  The  cardinal  signs  of  inflammation  are  also 
wanting,  especially  as  to  local  temperature,  pain,  and  redness.  Only 
when  the  inflammatory  process  involves  the  skin  follicles  is  there  red- 
ness, and  even  then  it  is  only  a  dull  liluish-red.  If  mixed  infection 
occurs,  as  does  occasionally  happen,  then  the  clinical  history  rather  than 
the  local  appearance  aids  in  determining  its  nature.  The  skin  having 
been  broken,  or  opened  by  the  surgeon,  tistulte  result.  The  sinuses 
leading  to  the  tuberculous  foci  are  lined  by  tuberculous  granulation 
tissue,  and  their  orifices  present  the  dull  gray,  pale,  edematous,  often 
diphtheroid,  appearance  which  is  so  typical.  These  siniTses  may  persist 
for  weeks,  months,  or  years,  and  when  they  heal  they  may  cicatrize  so 
strongly  as  to  make  the  deep  craterlike  scars  so  often  seen. 

Treatment. — The  only  rational  treatment  of  localized  tuberculosis 
of  bone  is  surgical.  Whatever  the  procedure  employed,  and  it  will,  of 
course,  vary  for  different  bones,  it  must  he  radical  to  be  efficient. 

TUBERCULOSIS  OF   SPECIAL   BONES 

Cranial  Vault. — I'ntil  the  surgeon  has  learned  to  appreciate  prop- 
erly the  fact  that  the  disease  spreads  in  the  vascular  layer  of  the  diploe 
far  beyond  any  external  evidences,  liis  operative  intervention  will  be 
futile.  It  is  al)solutely  essential  to  remove  the  external  plate  until  all 
of  the  granulating  layer  has  been  uncovered,  and  the  normal  vascular 


734 


TUBERCULOSIS   OF   BONES  AND  JOINTS 


area  is  exposed  on  all  sides.  Healthy  ai-eas  ai'e  easily  recognized.  The 
disease  usually  presents  itself  as  a  painless,  fluctuating,  nonfebrile  mass 
beneath  the  scalp,  which  on  opening  presents  the  characteristic  of  a 
"  cold  abscess  " — a  cheesy,  flocculent  pus. 

Ribs. — Here,  as  in  the  cranial  vault,  the  disease  is  of  the  rapidly 
infiltrating  type,  with  the  point  of  inception  most  frequently  at  the 

cartilaginous  Junction.  Until  the 
periosteuni  has  perforated  and  the 
cold  abscess  begun  to  form,  it  nuiy 
escape  detection  by  the  surgeon,  or 
be  unsuspected  by  the  patient. 
Clinical  experience  has  shown  that 
the  old  "  caries  costarum  "'  need 
no  longer  be  a  "  bete  noire  "  to  the 
surgeon.  It  is  known  that  the  dis- 
ease spreads  beyond  the  apparent 
localization,  and  partial  ojx'rations, 
curettings,  etc.,  for  the  radical  re- 
moval of  the  gi'eater  part  of  the  rib 
have  been  abundant.  Spontaneous 
fracture  occasionally  results. 

Sternum. — Tuberculosis  of  the 
sternum,  though  five  times  less  fre- 
quent tlian  tuberculosis  of  the  rib, 
presents  similar  conditions.  It  is 
somewhat  singular  that  these  bones 
escape  early  infection,  persons  of 
middle  age  being  the  ones  chiefly 
affected.  The  thickening  of  the 
sternal  periosteum,  and  the  collec- 
tion beneath  it  of  tuberculous  de- 
tritus, presents  at  first  a  tumefac- 
tion (cold  abscess),  usually  with- 
out redness,  that  later  terminates 
in  a  fistula.  Througli  these  fistulas 
softened  bone  is  usually  to  be  felt. 
Perforation  of  the  sternum  fre- 
quently occurs,  with  the  production 
of  a  mediastinal  abscess. 

Vertebrae.  —  Because    of    the 

frightful    deformities,    as    well    as 

spinal-cord  involvements,  which  tuberculosis  of  the  vertebras  may  produce, 

early  recognition  of  its  presence,  with  the  mechanical  and  surgical  treat- 


FiG.  177. — Case   of   Pott's   Disease. 
(Sea  Breeze,  Coney  Island.) 


TUBERCULOSIS   OF    JOINTS  735 

nient  wliicli  that  ini{)lies,  was  insisted  on  bv  Pott  (  17T!»).  When  the  pres- 
sure absorption  of  the  unusually  light  spongy  cancellous  tissue  by  a  tuber- 
culous osteitis  takes  place,  the  result  is  a  flattening,  and  the  well-known 
deformity.  This  is  peculiarly  the  tuberculosis  of  early  youth  (second 
to  fifth  years),  probably  because  of  the  greater  liability  to  trauma  here 
than  in  other  bony  areas.  Motion,  too,  being  persistent,  varied,  and 
continuous,  proves  a  constant  irritating  factor  of  serious  moment.  Oc- 
casionally a  necrosing  tuberculous  osteitis  results  in  rapid  death  of  the 
bonia  without  the  formation  of  excessive  granulation  tissue,  due  probably 
to  embolic  arterial  infarcts.  Here,  as  elsewhere,  is  observed  the  cold 
abscess,  which,  influenced  both  by  gravity  and  the  fasciae,  results  in  tlie 
best-kno^^Ti  of  all  cold  abscesses,  tlie  psoas  al)scess. 

TUBERCULOSIS    OF    JOINTS 

We  may  now  pass  to  the  consideration  of  tliis  disease  as  it  affects 
the  articular  ends  of  long  hones,  tuberculosis  of  the  smaller  bones,  except 
the  vertebra^  l)eing  of  less  clinical  importance.  Knowing  the  anatomic 
peculiarities  of  the  epiphyseal  circulation,  it  is  easy  to  understand  why 
the  infection  so  frequently  attacks  the  articular  side  of  the  epiphyseal 
cartilage,  where  the  blood  current  is  slower  and  the  vessels  terminate 
in  blunt  extremities.  Likewise  clear  is  the  sequence  of  joint  involve- 
ment, since  escape  of  tuberculous  detritus  takes  place  more  easily  into 
the  joint  than  through  the  denser  outer  layei-  of  the  shaft.  We  find, 
therefore,  a  large  pro])ortion  of  joint  invasions  occurring  in  tliis  manner. 
Joint  tuberculosis  always  affects  either  (1)  the  neighboring  hone  or 
(2)  the  synovial  membrane.  The  cartilages,  the  ligaments,  the  capsule 
are  never  the  primary  site  of  infection. 

Symptoms. — When  the  joint  becomes  thus  invaded  from  the  bony 
side  there  can  be  no  characteristic  prodromal  history,  since  the  deter- 
mining factors  of  size,  location,  rapidity  of  growth  of  the  infective 
focus,  as  well  as  the  gradual  or  sudden  emptying  into  the  joint  of  the 
infective  material  vary  so  widely.  Hence,  in  these  cases  the  first  definite 
manifestation  may  be  impairment  of  motion  or  swelling  of  the  joint. 
Tubercular  foci  in  bone  are  slow  to  produce  clinical  symptoms,  the 
invasion  of  the  more  sensitive  joint  structures  or  the  periosteum  often 
being  the  first  thing  to  attract  the  attention  of  tiie  patient.  When 
this  occurs  there  may  be  a  fixation  of  the  part,  due  to  muscular  spasm. 
Contractures  which  in  certain  joints  limit  motion  in  certain  directions 
are  very  significant.  If  these  contractures  persist  or  the  disease  pro- 
gresses, certain  characteristic  postures  or  deformities  result  that  are 
considered  pathognomonic.  Too  frequently  pain  is  so  slight  as  to  be 
ignored  by  the  patient,  or  it   is  ascribed  by  the  physician  or  patient 


736  Tt'BERCrLOSlS   OF   BONES  AND  JOINTS 

to  rheumatism,  "growing  pains,"  etc.,  when  if  all  available  diagnostic 
means  were  utilized,  such  as  the  X-ray,  inoculation  tests,  the  opsonic 
index,  v.  Pirquet's  test,  Calmette's  reaction,  or  the  search  for  other  foci, 
many  a  joint  might  be  spared  invasion  and  there  would  be  fewer  cripples. 

That  heredity  exerts  some  influence  is  probable,  though  congenital 
tuberculosis  is  extremely  rare.  The  physical  -condition  of  the  patient 
does  not  necessarily  bear  any  relationship  to  the  tuberculous  joint;  the 
patient  may  be  in  perfect  health  otherwise.  This  may  be  true  even 
when  there  is  ^  collection  of  pus  in  the  joint,  or  when  the  patient  has 
an  incipient  pulmonary  tuberculosis. 

Prognosis. — It  must  ever  be  borne  in  mind  tbat  a  real  or  symp- 
tomatic cure  may  take  place,  and  that  tlio  tuliercular  foci  may  become 
encapsulated  and  dormant.  Some  authorities  claim  that  in  sucli  cases 
there  will  be  a  recurrence  within  fifteen  years;  others,  I)efore  the  age 
of  forty-five.  Direct  danger  to  life  is  present  in  the  purulent  forms, 
and  through  septic  infection  of  tuberculous  abscesses,  which  may  lead 
to  acute  fatal  septicemia  or  p3'emia,  or  to  sucli  chronic  sepsis  as  may 
ultimately  cause  the  death  of  the  patient  through  degenerative  changes 
in  the  viscera.  As  a  general  rule,  death  results  in  forty-six  per  cent  of 
suppurative  joints,  in  twenty-five  per  cent  of  the  nonsuppurative,  usu- 
ally from  some  acute  invasion  of  the  lungs,  kidneys,  intestines,  by  the 
same  process.  Those  joint  invasions  developing  from  bone  foci  never 
heal  spontaneously,  and  rarely  by  nonoperativc  treatment.  In  twenty- 
five  per  cent  (55  out  of  200)  of  the  cases  appropriate  for  conservative 
treatment,  a  movable  joint  is  secured  there])y. 

The  characteristic  of  a  tuberculous  joint  is  the  tuberculosis  of  its 
synovial  membrane.  This  may  be  primary  in  the  sense  that  the  tubercle 
bacilli  were  l)rought  to  the  joint  by  the  circulation  (about  eleven  per 
cent),  l)ut  it  is  often  secondary  to  an  infection  extending  from  a  bony 
focus  in  close  proximity  to  the  joint  structures.  No  matter  how  the 
infection  occurs,  the  synovial  membrane  presents  the  same  changes.  As 
in  other  serous  membranes,  the  first  effect  of  the  tuberculosis  is  to 
produce  an  exudate,  in  this  case  of  a  sero-fibrinous  nature.  Koenig 
considers  the  fibrin  the  most  important  constituent,  since  this  coagu- 
lates and  makes  de])osits  on  the  various  surfaces  of  the  joint.  These 
fibrinous  dejjosits  usually  become  organized,  capillaries  extend  into  them 
from  below;  miliary  granulations  appear;  free  particles  likewise  become 
fused,  fibrous,  and  ultimately  constitute  the  ricelike  bodies  or  sago  grains 
of  a  tuberculous  joint.  The  newly  formed  tissue,  granulating  in  char- 
acter, may  rise  from  the  surfaces  of  the  joint  like  a  papilloma. 

Whether  the  watery  constituent  of  the  exudate  remains  to  produce 
a  hydrops,  or  whether  it  is  absorbed,  leaving  behind  the  newly  organ- 
ized tissue,  is  of  small  importance.     It  is  only  in  the  very  early  stage 


TUBERCULOSIS  OF   JOINTS  737 

that  the  freshly  deposited  fibrinous  material  is  seen,  and  it  is  then  that 
local  medication  may  be  effective.  In  the  later  stages,  when  the  vascular 
proliferation  from  the  s3-novial  membrane  has  become  marked,  ulceration 
of  the  cartilage  and  exposure  of  the  bone  beneath  may  take  place.  The 
cartilage,  therefore,  plays  only  a  passive  part. 

When  the  joint  infection  has  had  its  origin  in  a  bony  focus,  or  in 
a  large  cheesy  focus  in  the  synovial  membrane,  a  purulent  joint  may 
result — that  is,  in  the  sense  of  a  "  cold  abscess."  "  Why  the  pus  occurs 
we  do  not  know.  The  bacilli  are  not  the  cause,  since  they  are  rarely 
to  be  found.  Since  other  bacteria  are  not  the  cause,  we  are  of  the 
opinion  that  the  formation  of  toxins  by  the  tubercle  bacilhis  causes 
the  caseous  suppuration"  (Koenig).  Motion  may  be  said  to  favor  its 
formation  and  development.  The  pus,  although  containing  few  leuco- 
cytes and  fewer  bacilli,  is  still  very  infectious   (spores?). 

In  1894  Koenig  wrote:  "It  would  be  undoubtedly  a  great  advantage 
if  one  could  early  recognize  the  osteotubercular  cases  and  those  in  which 
a  spontaneous  healing  could  not  be  awaited,  for  then  an  early  operation, 
with  the  patient  in  good  condition,  offers  the  ideal  results." 

In  1899  the  writer  called  attention  to  the  extreme  value  of  the 
X-ray  as  a  diagnostic  aid  in  supplying  this  desideratum,  for  with  it  it 
is  often  possible  to  determine  the  size,  location,  and  type  of  bony  infil- 
tration. The  wedge-shaped  focus  is  not  always  shown  by  this  means. 
That  there  does  exist,  in  about  a  third  of  the  cases,  more  than  one  bony 
focus  can  often  thus  be  demonstrated,  and  it  is  of  great  surgical  import. 

A  clear  understanding  of  the  general  characteristics  of  a  joint  tuber- 
culosis, in  the  three  forms  in  which  it  manifests  itself,  will  render  easy 
the  application  of  that  knowledge  to  tuberculosis  of  special  joints,  in 
which  the  clinical  course  will  vary  as  the  function,  the  structure  or 
location  prove  determining  factors.  These  three  varieties,  to  use  Koe- 
nig's  classification,  are: 

1.  Hydrops:  Hydrops  serosus,  hydrops  fibrinosus. 

2.  Tumor  alhiis:  Fungous,  granulating  joint,  "white  swelling"    (a 

late  form  of  hydrops). 

3.  Tvhrrcnlous  suppurative  arthritis. 

When  the  primary  synovial  tuberculosis  has  advanced  beyond  the 
fibrinous  stage  to  the  organized  granulating  stage,  with  or  without  the 
hydrops  remaining,  there  results  the  second  variety,  or  tumor  albus 
("white  swelling").  We  here  find  more  or  less  destructive  ulceration 
of  cartilage,  perforations  of  or  loosening  of  it  from  the  Ijone  beneath 
by  a  tuberculous  osteitis.  The  joint  becomes  lined  with  granulations, 
sometimes  so  pedunculated  as  to  give  to  this  stage  tlie  name  fungus,  or 
villous.  Kecovery  is  still  possible,  but  alwaj^s  with  imperfect  mobility. 
If,  as  sometimes  occurs,  the  fluids  are  absorbed,  the  condition  is  termed 
48 


738  TT'BERCULOSIS  OF   BONES  AND   JOINTS 

a  di-v  ai'lliritis,  or  arthritis  tubereiilosa  sicca.  In  eitlior  case  \hv  joint 
takes  on  a  spindle  shape  1)ecaiise  of  muscular  atropliy,  thickening  of 
tlie  periarticuhir  tissues,  and  atropliy  of  the  shaft.  Tumor  alius  is  not 
confined  to  the  knee,  with  which  it  is  usually  associated,  but  it  may 
affect  any  joint. 

Following  either  the  hydrops  stage  or  the  tumor  albus,  and  more 
rarely  developing  spontaneously,  as  if  from  an  acute  miliary  infection, 
is  the  third  variety  of  this  joint  affection — the  purulent  tuberculous 
arthritis.  In  this  variety  the  joint  is  filled  with  a  purulent  fluid;  its 
synovial  membrane  is  covered  with  a  tuberculous  exudate,  in  which 
miliary  bodies  are  to  be  found.  The  purulent  variety,  whether  orig- 
inating from  a  bony  deposit  breaking  into  the  joint  or  primarily  from 
the  synovial  membrane,  has  a  mortality,  as  compared  with  the  non- 
purulent forms,  of  nearly  two  to  one,  no  matter  whether  treated  con- 
servatively or  by  operation. 

Diagnosis. — As  in  tu])erculous  processes  elsewhere,  there  is  an  even- 
ing rise  of  temperature  to  aid  in  the  diagnosis.  While,  usually,  a  joint 
invasion  is  single,  it  may  become  multiple.  When  this  occurs,  the  vary- 
ing degrees  of  advancement  of  the  process  will  likewise  assist  in  deter- 
mining the  nature  of  the  lesion.  These  multiple  nuinifestations  go  to 
prove  that  miliary  tuberculosis  is  not  always  fatal.  This  agrees  with 
the  experience  of  the  writer,  who  has  observed  the  acute  miliary  tuber- 
culosis provoked  by  a  resection  of  the  hip-joint  terminate  in  recovery, 
even  when  the  case  presented  tlie  classical  symptoius  of  tuberculous 
meningitis.  If  we  do  not  consider  the  (|uestion  of  function,  it  can  be 
stated  that  the  large  nuijority  of  joint  invasions  heal  symptonuitically. 

It  is  agreed  that  pain  is  not  characteristic,  many  of  the  joints  l)eing 
surprisingly  free  from  pain,  considering  the  objective  involvement.  Sore- 
ness on  pressure  at  the  articular  margins,  associated  with  a  pronounced 
synovial  thickening;  the  peculiar,  grating  "feel"  of  the  slipping  of 
rice  bodies  or  synovial  fringes  between  its  layers,  aid  in  the  diagnosis, 
but  are  not  absolutely  pathognomonic.  The  only  ab.^olutely  positive  evi- 
dence in  the  early  stages  will  l)e  by  the  demonstration  of  the  bacillus 
in  the  fluids  withdrawn.  Positive  results  ol)tained  by  the  inoculation 
of  animals  are  also  valuable.  This  may  be  tested  during  the  period  of 
conservative  treatment  or  during  the  preparation  of  the  joint  prior 
to  operation.  Among  the  newer  aids  to  diagnosis,  two  are  of  special 
importance,  and  promise  much  for  the  future.  They  are  (1)  v.  Pir- 
quet's  phenomenon  and  (2)  Wright's  determination  of  the  opsonic  index. 

Koch's  demonstration  that  tuberculous  individuals  react  to  tuber- 
culin in  a  specific  manner  has  largely  been  abandoned  because  of 
untoward,  even  dangerous,  sequelce.  V.  Pirquet,  however,  has  re- 
cently shown  that  the  routine  abrasion  made  preliminary  to  vaccina- 


TUBERCULOSIS   OF   JOINTS  739 

tion  against  sinal]i)OX,  if  nioistciu'd  with  iulicvculin  (Kocli),  will,  in  a 
tuberculous  iudividual,  produce  a  characteristic  local  reaction.  To  de- 
termine the  normal  reaction  to  such  a  scraping  away  of  the  epithelium, 
two  areas,  an  inch  or  more  apart,  are  scraped  lightly.  Only  one  of 
these  is  moistened  with  tuberculin;  the  other  serves  as  a  control.  If 
the  individual  is  nontuberculous,  the  two  abrasions  react  alike;  if  he 
is  tuberculous,  a  reddened  area,  becoming  more  or  less  crusted,  appears. 
The  reaction  occurs  during  the  first  tw^enty-four  hours.  Sufficient  ex- 
perimentation along  these  lines  has  already  been  done  to  demonstrate 
that  the  method,  while  not  infallible,  is  very  suggestive,  particularly 
when  applied  to  children  under  six  years  of  age. 

Wright  demonstrated  that  the  phagocytic  activity  of  a  tuberculous 
person's  leucocytes  to  tubercle  bacilli  varies  from  the  normal,  and 
that  this  variation  is  caused  by  the  opsonins.  Their  presence  in  the 
serum  prepares  the  bacillus  for  ingestion  by  the  leucocyte.  Their  ab- 
sence leaves  the  bacillus  uningested.  Hence,  varying  amounts  of  opso- 
nins cause  varying  degrees  of  phagocytosis.  By  comparing  the  serum 
of  the  individual  suspected  of  being  tubercnlous  with  the  mixed  sera 
of  several  individuals  known  to  be  free  from  tuberculosis,  there  is 
obtained  an  index  to  the  diagnosis  and  to  the  treatment.  This  Wright 
has  named  the  opsonic  index.  Drs.  Lincoln  and  Vail  have  proved  that 
there  is  a  normal  tuberculo-opsonic  index,  and  that  the  diagnostic  value 
of  variations  from  the  normal  is  extremely  great  (eighty-five  per  cent), 
when  several  careful  examinations  have  been  made,  thus  corroborating 
Wright's,  Douglas's,  and  Bullock's  claims. 

The  writer  is  convinced  that  persistent  fluctuations  from  the  normal 
index  are  diagnostic  of  tuberculosis.  (The  details  of  this  subject  are 
more  elaborately  treated  elsewhere.)  Hence,  in  a  given  joint,  if  there 
is  an  active  tul)erculous  process  there  will  be  found  departures  from 
the  normal  index,  usually  lowered,  sometimes  raised,  occasionally  fluc- 
tuating. Indeed,  the  fluctuation  is  very  significant  when,  having  de- 
termined the  patient's  index  beforehand,  the  suspected  joint  is  mas- 
saged; for  by  so  doing  the  exciting  factors  of  opsonin  production  nuiy 
!)('  driven  into  the  circulation,  thus  changing  the  index,  usually  raising 
it  nuirkedly. 

Treatment. — In  a  majority  of  the  cases  the  X-ray  serves  as  an  aid 
in  deciding  whether  there  is  much  hope  of  recovery  from  conservative 
orthopedic  measures.  In  this  condition,  more  than  in  others,  is  it 
necessary  to  consider  every  factor  to  individualize.  Surgical  interven- 
tion is  indicated — 

( 1 )  When  the  constitutional  condition  of  the  patient  shows  a  pro- 
gressive deterioration  under  treatment.  This  may  mean  (a)  sepsis, 
from  absorption  of  the  products  of  a  mixed   infection  in  the  joint  or 


740  TUBERCULOSIS   OF    BONES  AND   JOINTS 

sinuses;  (b)  amyloid  degeneration  of  the  viscera;   (c)  pulmonary  inva- 
sion;  (d)  diarrhea. 

(2)  The  age  of  the  patient  should  influence  the  decision,  reluctance 
to  operate  in  very  early  youth  and  after  thirty  growing  progressively 
greater;  in  youth,  because  the  danger  of  disturbance  of  future  develop- 
mental centers  becomes  greater,  therefore  the  end  results  are  worse; 
in  later  years,  because  clinical  experience  has  shown  that  adults  bear 
joint  resections  poorly. 

(3)  The  environment  of  the  patient  should  be  a  factor  in  deter- 
mining earlier  operation.  However  illogical  it  may  at  first  thought 
appear  to  make  one  rule  for  the  rich  and  another  for  the  poor,  it  still 
is  practical  and  necessary  to  consider  the  fact  that  the  child  of  a  day 
laborer  cannot  undergo  the  long,  expensive  trial  of  orthopedic  and 
climatic  measures,  occasionally  justifia1)]e  in  the  child  of  the  rich,  only 
to  submit  to  resection,  with  its  attendant  expense  and  delay,  in  the  end. 

(4)  Since,  as  before  stated,  it  is  often  possible,  by  means  of  the 
X-ray,  to  locate  the  disease  and  to  determine  the  exact  part  and  propor- 
tion of  joint  affected,  it  is  conceivaljle  how,  witli  a  location  favorable  for 
removal,  an  unusually  early  operation  might  be  justified.  Conversely, 
how  in  the  absence  of  evident  1)one  disease  the  case  should  1)e  treated 
as  one  of  primary  synovial  tuberculosis.  The  writer  has  always  pro- 
tested against  the  routine  treatment  of  any  joint,  first  by  mechanisms, 
then  by  mechanisms  plus  injections,  and  finally  by  operation.  Surgeons 
have  too  frequently  been  satisfied  with  a  diagnosis  of  tuberculosis  of  a 
joint  (without  regard  to  whether  it  be  (1)  osteotuberculosis  of  one 
or  both  bones,  (2)  primary  synovial  tuberculosis,  or  (3)  tuberculosis 
near  the  joint,  but  not  in  it),  and  then  proceeded  contentedly  to  the 
application  of  mechanical  devices  for  the  rest  and  protection  of  the 
joint,  with  or  without  iodoform  injections,  and  without  regard  to  the 
exact  location  of  the  infective  center. 

Those  eases  that  are  cured  by  Mosetig's  glycerin-iodoform  and  its 
analogues  are  cases  in  which  the  disease  was  primarily  synovial  in 
origin,  and  remained  so.  This  is  the  only  form  in  which  there  may  be 
a  restitutio  ad  integrum,  and  the  time  necessary  tliereto,  even  in  simple 
cases,  is  often  one  to  two  years !  It  is  reasonable  to  assume,  and  the 
assumption  is  borne  out  by  clinical  experience,  that  the  beneficial  action 
of  iodoform  is  essentially  by  contact.  Hence,  it  is  not  reasonable  to 
expect  that  a  focus  buried  in  the  articular  end  of  a  bone,  whose  products 
have  broken  through  some  minute  opening  into  the  joint,  will  be  influ- 
enced essentially  by  iodoform  thrown  into  that  joint !  Hence  the  neces- 
sity for  refinement  in  diagnosis  and  the  determination  whether  it  is 
an  osteotuberculosis  or  a  synovial  infection.  Since  anatomic  and  path- 
ologic  findings   and  clinical  experimental   evidence   teach   that  only   a 


\ 

TUBERCULOSIS  OF   JOINTS  741 

small  projxjrtion  of  case?^  are  of  primary  synovial  origin,  it  follows  as 
a  corollary  that  only  a  small  proportion  will  be  cured  l)y  iodoform 
treatment.  Time  has  shown  that  it  was  essentially  in  those  cases  in 
which  the  iodoform  came  in  contact  with  the  diseased  surfaces — i.  e., 
synovial  tuberculosis — that  healing  occurred.  In  these  large  tuberculous 
abscesses  of  joints  the  contents  should  be  removed  prior  to  the  iodoform 
injections,  though  this  may  even  require  at  times  small  incisions,  the 
material  being  too  flocculent  to  flow  through  needles.  Hence,  it  is 
well  to  limit  injections  to  those  joints  wdiere  the  clinical  history  and 
the  X-ray  examination  showed  the  case  to  be  one  of  synovial  tuber- 
culosis. 

Of  course,  the  intelligent  physician  will  in  no  case  neglect  any  of 
the  other  factors,  general  or  local,  which  tend  to  improve  the  patient's 
condition;  hence,  immobilization  of  the  joint,  in  so  far  as  is  indicated; 
the  use  of  Bier's  hyperemia;  alternately  flooding  the  diseased  area 
with  opsonins;  minute  doses  of  tuberculin  T.ll.  (yoVo  mgm.)  to  stimu- 
late the  production  of  opsonins;  the  actinic  rays  of  the  sun  (in  larger 
measure  found  in  X-rays)  to  increase  metabolic  changes  in  the  embry- 
onal tissues  present,  will  all  favor  healing.  The  extremely  beneficial 
action  of  direct  exposure  to  the  sun's  rays  cannot  be  emphasized  too 
strongly. 

Healing  usually  takes  place  by  fibrous  cicatrization.  When,  how- 
ever, the  healing  is  complicated  by  a  cold  abscess,  often  noted  under 
the  Bier  treatment,  proper  surgical  care  of  the  same  should  be  instituted 
early — i.  e.,  evacuation  under  aseptic  precautions. 

It  should  be  recalled  that  Bier  excepts  hydrops  as  not  being  amen- 
able to  his  treatment,  and  urges  not  too  prolonged  fixation.  In  the 
case  of  the  knee-  and  ankle-joints  he  urges  operative  treatment  earlier 
than  in  other  joints,  because  the  principal  goal — a  functionating  joint — 
is  here  least  often  obtained  by  passive  hyperemia.  Otherwise  his  re- 
sults have  been  so  good  that  army  service  was  almost  enforced  on 
some  of  his  patients. 

When  the  tuberculosis  is  in  such  close  proximity  to  the  joint  as  to 
simulate  joint  disease,  even  when  sinuses  exist,  such  a  joint  may  be 
spared  resection  if  the  surgeon  traces  the  sinus  to  its  source  before 
incising  the  joint.  In  this  way  the  writer  has  saved  four  hii)-joints 
presenting  almost  all  the  classical  joint  symptoms  (see  special  joints) 
due  to  foci  situated  in  the  ilium  close  to  the  acetabular  margin,  but 
external  to  the  joint.  Broca,  too,  emphasized  this  fact.  "  When  the 
diagnosis  can  be  made  of  isolated  ca])sule  disease  (tul)erculous  fibroma) 
it  should  be  treated  like  a  new  growth — removed"   (Koeiiig). 

Wlii'ii  surgical  intervention  is  indicated  (and  it  is  in  ncai-ly  fifty 
per  cent  of  cases)   For  a  tuborcnlmis  joint,  what  shall  be  (lie  pi-occdure? 


742  TUBERCULOSIS   OF    BOx\ES  AND   JOINTS 

Either 

(1)  Extirpation  of  the  synovial  membrane  (arthrectomy), 

(2)  Excision  of  the  joint  (resection),  or 

(3)  Amputation. 

Arthrectomy  has  been  tried  with  success  in  those  cases  of  synovial 
tuberculosis  which  have  resisted  the  usual  conservative  treatments,  and 
c(msists  in  the  thorough  removal  of  all  diseased  synovial  tissue.  Care 
must  be  taken  to  ol)tain  the  most  desirable  position  for  the  ankylosis 
which  usually  occurs.  In  every  useless  position  correction  should  at 
the  same  time  be  made.  When  the  disease  has  been  of  osteal  origin, 
one  can  sometimes  make  a  partial  arthrectomy  if  the  focus  be  small, 
or,  if  extensive,  it  may  require  the  resection  of  the  articular  ends,  pre- 
serving, if  possible,  the  epiphyseal  cartilage,  since  on  this  future  growth 
depends.  In  the  lower  extremities  the  epiphysis  nearest  the  knee,  and 
in  the  upper  extremities  the  epiphysis  farthest  from  the  elbow,  exert  the 
greater  influence  on  future  bone  growth. 

In  adults  with  suppurative  joints  arthrectomy  gives  a  lower  mor- 
tality than  resection,  probably  because  the  vessels  of  bone  are  not  opened. 
When  the  structures  in  and  about  the  joint  are  too  extensively  involved, 
or  when  the  mixed  infection  is  producing  a  dangerous  toxemia,  or  when 
there  is  amyloid  degeneration  of  other  organs,  it  may  even  be  necessary 
to  amputate  the  member  to  save  the  patient's  life.  In  these  healed 
joints  with  ankylosis,  at  some  later  period,  Murphy  has  demonstrated 
how  excellent  functional  results  may  be  obtained  by  the  interposition 
of  the  subcutaneous  cellular  tissue  between  the  articular  ends. 

TUBERCULOSIS    OF    SHOULDER-JOINT 

Occurrence. — Altliough  tuberculosis  of  the  shoulder-joint  is  relatively 
rare  (knee  six  times  as  frequent),  either  variety  of  invasion  may  be 
met  with,  ranging  in  frequency,  respectively,  (1)  bony  focus  in  humeral 
head,  (3)  primary  synovial  tuberculosis,  (3)  bony  focus  in  glenoid 
process  of  scapula. 

Symptomatology. — Aside  from  some  vague  sense  of  pain  and  dis- 
comfort about  the  shoulder,  there  may  be,  in  the  early  stage  of  the  first 
and  prevailing  form,  practically  no  other  symptom.  An  X-ray  picture 
may  reveal  the  location  and  extent  of  the  focus,  the  nature  of  which 
could  then  be  confirmed  by  the  methods  mentioned  in  the  preceding 
pages.  If  the  lesion  has  invaded  the  joint,  thus  infecting  the  articu- 
lation, or  if  the  disease  primarily  invaded  the  synovial  membrane,  there 
tlien  follow  effusion,  swelling  of  joint,  limitation  of  motion,  and  severe 
pain.  Eice  l)odies  are  found  next  in  frequency  to  knee.  .\n  early 
involvement  or  destruction  of  the  biceps  tendon,  with  the  resulting  cold 


TUBERCULOSIS   OF    JOINTS  743 

al)scess  course,  is  determiiii'd  liy  the  same.  When  the  caj)siihir  perfora- 
tion is  near  the  insertion  of  tlie  other  tendons,  sinuses  develop  and  fol- 
low the  course  of  these  tendons. 

Differential  Diagnosis. — The  slow  onset,  the  ahsence  of  marked  fe- 
bi'ile  disturbances  and  redness,  aid  in  differentiating  the  condition  from 
simple  rheumatism;  absence  of  gonorrheal  history  or  discharge,  with 
normal  gonococcal  index,  differentiate  it  from  gonorrheal  arthritis,  while 
the  low  tuberculo-opsonic  index,  the  character  of  the  aspirated  fluids, 
their  infectivity  to  the  joints  or  peritoneum  of  the  animals,  together 
with  the  family  history,  the  slight  evening  rise  of  temperature,  will 
make  reasonably  clear  the  character  of  the  infection. 

Prognosis.— Clinicians  agree  that  the  mortality  of  shoulder-joint  in- 
fections exceeds  that  of  other  joints,  though  in  an  indirect  manner — 
i.e.,  by  pulmonary  (forty  per  cent)  or  other  fatal  internal  invasion. 
Koenig  considers  the  prognosis  for  healing  very  unfavorable.  Earely 
do  the  fistulas  close  up.  Conservative  treatment  fails  to  help  the 
caries  sicca,  and  the  best  prognosis  is  found  in  those  cases  in  which 
the  disease  can  be  removed  by  operation.  Operation  is  attended  by 
twent3'-five  per  cent  mortality,  directly  or  indirectly ;  seventy-five  per 
cent  of  patients  have  more  or  less  useful  joints,  limitation  of  abduction, 
elevation,  and  rotation  being  the  chief  deficiencies. 

Treatment. — If  the  diagnosis  is  made  prior  to  the  invasion  of  the 
joint,  too  much  time  should  not  be  wasted  in  conservative  treatment, 
fixation,  etc.,  but  early  surgical  intervention  is  necessary.  When  there 
is  evidence  of  slight  bono  involvement,  and  yet  joint  effusion,  enlarge- 
ment, capsule  thickening  (often  detectable  at  the  bicipital  groove,  where 
it  occasionally  is  localized),  and  other  factors  going  to  make  up  the 
symptom-complex  of  tumor  albus  are  present,  iodoform-glycerin  injec- 
tions may  prove  efficacious.  The  writer  has  seen  such  joints  restored 
to  apparent  perfect  function  thereby,  even  with  jirogressing  pulmonary 
invasion  and  double  psoas  abscess  in  the  same  individual. 

The  possibility  of  occasional  tuberculosis  of  the  subdeltoid  bursa, 
without  joint  involvement,  must  be  borne  in  mind. 

When  abscesses  and  fistula?  exist,  nothing  remains  but  surgical  inter- 
vention, Avhich  should  seldom  be  limited  to  opening  of  the  abscesses, 
curetting  the  fistulte;  a  resection  slmuld  be  done.  Experience  teaches 
that  milder  procedures  yield  poorer  results  here  than  elsewhere.  The 
shoulder  and  the  hip  do  not  permit  of  em])loying  Bier's  treatment. 

TUBERCULOSIS  OF  CARPUS  AND  TARSUS 

invasion  of  llicsc  areas  witli  Ihr  inrcclivc  clcnicnls  occuis  in  a  man- 
ner similar  to  that  descrilx'd  in  the  case  of  the  lai'ger  l)ones  and  joints. 


744  TUBERCULOSIS  OF   BONES  AND  JOINTS 

Occasionally  a  single  bone  or  joint  is  involved,  and  the  surgeon  may,  by 
early  interference,  save  the  remaining  unaffected  joints.  (The  scaphoid 
is  exempt  from  primary  disease.)  Here,  however,  because  of  the  very 
small  size  as  well  as  the  intimate  relationship  of  one  wdth  another,  and 
the  frequent  existence  of  but  one  synovial  membrane  for  several  articu- 
lar facets,  it  is  rarely  possible  to  decide  whether  the  invasion  has  been 
primarily  osteal  or  synovial.  In  either  event,  both  early  become  merged. 
The  treatment  does  not  differ  from  that  employed  elsewhere,  but 
inasmuch  as  there  is  usually  both  bone  and  synovial  involvement,  the 
injection  treatment  is  rarely  employed.  Protection  from  trauma,  im- 
mobilization, exposure  to  direct  sunlight  (after  the  removal  of  the  bony 
foci  of  the  process  has  gone  on  to  the  formation  of  a  cold  abscess  or 
fistula),  will  give  the  patient  the  best  chance,  ultimately  checking  the 
process  and  leaving  a  useful,  if  impaired,  part. 

TUBERCULOSIS    OF    HIP-JOINT 

True  cases  of  primary  synovial  tul)erculosis  of  the  hip-joint  are  rare, 
and  seldom  are  adapted  to  the  iodoform-injection  treatment.  When 
it  does  occur,  however,  the  effusion  is  less,  the  pathologic  changes  are 
less  marked,  the  granulations  about  the  cartilaginous  margins  are  less 
extensive,  the  amount  of  fibrin  is  less,  and  fewer  rice  bodies  are  ob- 


FiG.  178. — Characteristic  Position  of  Tuberculous  Hip-Joint. 
Muhiple  fistulae. 

served  than  in  the  knee-joint  or  other  joints.  The  caseous  products 
from  the  primary  .synovial  form  (or  from  that  of  osteal  origin)  tend  to 
accumulate  about  the  neck  of  the  femur,  close  to  the  trochanters,  thus 
producing  a  tumor  nuiss  whose  volume  is  increased  liy  the  thickening 
of  the  synovial  meml)rane,  and  it  can  usually  be  palpated  prior  to  per- 
foration of  the  capsule. 

From  the  fact  that  tuberculosis  of  this  joint  is  observed  twice  as 
frequently  in  tlie  male  as  in  the  female,  the  inference  is  drawn  that 
trauma   is   a   strong  exciting   factor.      Likewise,   its   occurrence   before 


TUBERCULOSIS  OF   JOINTS  745 

the  i\'^v.  of  lil'twii,  ill  eighty  \h'V  cent  of  ;ill  casos,  emphasizes  thai 
it  manifests  a  predilection  for  the  early  period  of  life.  In  fifteen 
j)er  cent  of  the  cases  trauma  is  the  exciting  cause,  but  infective 
fevers  such  as  scarlet  fever  (three  per  cent)  occasionally  supply  that 
factor. 

Hip-joint  tuberculosis  does  not  pursue  a  definite  course.  It  may 
alternately  improve  or  relapse,  whether  treated  by  the  best-recognized 
conservative  methods  or  left  nntreated.  Since  the  synovial  type  of  the 
disease  is  so  rare,  it  is  not  strange  that  Riedel  found  seventy  per  cent 
of  operative  cases  with  sequestra — i.  e.,  bony  foci. 

Because  of  the  superficial  resemblance  of  the  normal  ossific  centers, 
while  being  transformed  into  bone,  to  tubercular  sequestra,  care  must 
be  taken  not  to  remove  these  and  not  to  disturb  the  epiphyseal  car- 
tilage. This  is  especially  to  be  remembered  in  patients  between  the 
ages  of  two  and  ten  years. 

Elsewhere  reference  has  been  made  to  the  occasional  simulation  of 
chronic  hip  trouble  by  foci  outside  the  liip.  Hence,  the  preliminary 
step  in  every  fistulous  hip  should  be  to  determine  the  exact  point  to 
which  the  tract  leads  before  proceeding  to  make  the  classical  incisions 
for  partial  or  total  joint  resection. 

Sequestra. — A  large  proportion  of  all  cases  operated  on  (seventy 
per  cent — Kiedel)  are  found  to  contain  bony  foci  in  the  form  of  soft- 
ened tubercular  sequestra,  requiring  removal  to  effect  a  cure.  The  re- 
semblance, on  superficial  examination,  in  the  early  years  of  life  of  the 
normal  centers  of  ossification  to  these  tubercular  foci  has  occasionally 
led  to  their  removal,  with  a  loss  of  future  growth.  Only  when  they 
are  distinctly  tuberculous  should  they  be  removed. 

As  mentioned  elscAyhere,  the  bony  focus  is  occasionally  outside  of 
this  joint,  either  in  the  ilium,  trochanter,  or  neck  of  the  femur,  but 
in  such  close  proximity  to  the  joint  as  to  produce  most  of  the  usual 
hip-joint  symptoms.  If  the  surgeon  fails  to  determine  prior  to  his 
radical  intervention  the  points  to  which  the  sinuses  lead,  he  may  find 
himself  in  the  unpleasant  predicament  of  opening  a  joint  as  yet  unin- 
vaded.  In  the  absence  of  a  distinctly  demonstrable  "bony  crepitus,'' 
the  sinus  or  sinuses  should  be  traced  to  their  proper  origin.  By  ob- 
serving this  practice,  two  to  three  per  cent  of  the  hip- joints  will  escape 
unnecessary  opening. 

When  such  foci  break  into  the  joint,  and  the  condition  is  recognized 

early,  the  prognosis  of  operation  is  favoral)le.     The  X-ray  here  renders 

good   service  by   showing  the  clear-cut,   smooth,   articular   surfaces,   as 

yet  unmarred  Ijy  the  destructive  changes  so  common  in  the  later  stages. 

If  the   X-ray  shows  an  extensive  osteal  focus,  it  would   be  futile  to 

employ  palliative  measures. 
49 


746  TUBERCULOSIS  OF   BONP:S  AND   JOINTS 

Symptoms. — Puiu,  witli  partial  or  complete  fixation  of  the  joint, 
may  he  said  to  be  the  first  as  well  as  the  most  important  symptom 
to  attract  attention.  This  pain  is  a  soreness  provoked  by  motion  or 
weight  rather  than  a  sensation  independent  of  such  conditions.  (Noc- 
turnal pains  occur  through  movements  while  the  musculature  is  dor- 
mant.) The  occurrence  of  contractures  in  certain  muscles  or  groups 
of  muscles  is  to  lie  awaited,  but  tliese  are  no  longer  regarded  as  so 
ly]ucal  or  signidcant  as  was  foiincrly  taught.  Their  existence  for  any 
protracted  ])eriod  results  in  atrophy;  licnce  the  flattening  of  tlie  glu- 
teals and  obliteration  of  the  gluteal  fold. 

The  pain  may  be  referred  by  the  patient  either  to  the  hip-  or  knee- 
joint.  In  the  latter  case  it  is  due  to  a  reflex  passing  along  the  nerve 
trunk  supplying  sensation  both  to  the  hip-joint  as  well  as  to  the  an- 
terior aspect  of  the  thigh  and  knee.  This  may  be  the  only  pain  com- 
plained of  by  the  patient.  Provoked  by  the  friction  of  the  affected 
surfaces,  involuntary  muscular  contractures  occur  which  serve  to  min- 
imize it.  Unlike  all  other  joints,  however,  the  ball-and-socket  type  has 
all  its  articular  surfaces  in  constant  contact;  hence  variation  of  position 
cannot  wholly  relieve  the  affected  area  from  pressure.  At  the  same 
time  the  muscular  spasm  increases  the  undesired  pressure  and  friction, 
which  here,  as  elsewhere,  ends  in  pressure  atrophy,  with  absorption 
either  of  the  femoral  head,  if  that  be  the  chief  site  of  invasion,  or  of 
the  acetabular  margins,  or  both,  unless  prevented  by  appropriate  sur- 
gical intervention. 

As  a  corollary  to  the  above,  absorption  of  the  l)ony  head  and  neck, 
or  acetabular  margins,  and  shortening  (fifty  per  cent  of  cases)  ensues, 
made  evident  by  actual  measurement  and  subjective  findings.  As  the 
acetabulum  becomes  more  shallow,  partial  or  complete  luxation  of  the 
femoral  head  may  result  with  a  change  from  the  early  outward  to  the 
late  inward  rotation.  Rotation,  then,  is  an  early  sign  of  hip-joint 
involvement.  For  a  long  time  Bonnet's  experiments  have  been  ac- 
cepted as  explaining  this  rotation,  since  they  showed  that  the  position 
assumed  was  that  in  which  the  largest  amount  of  effusion  in  the  joint 
could  be  accommodated  with  least  tension — i.  e.,  abduction,  slight  flexion, 
and  outward  rotation — to  be  followed,  in  the  later  stage,  by  abduction, 
marked  flexion,  and  inward  rotation.  The  latter  is  the  more  serious 
because  it  is  indicative  of  more  extensive  disease.  Occasionally  this 
stage  is  observed  in  the  begipning  without  the  preceding  external  rota- 
tion.    It  is  indicative  of  an  extensive,  painful  bony  focus. 

When  the  disease  has  its  origin  in  the  acetabulum,  it  occasionally 
happens  that  the  Y  cartilage,  with  its  accompanying  wormian  bon(% 
succumbs  to  jhe  destruction,  followed  by  perforation  and  pelvic  (cold) 
abscess. 


TUBERCULOSIS  OF   JOINTS 


747 


Next  to  pain,  in  symptomatic  importance,  is  tlie  limp,  which,  seen 
a  few  times,  assumes  considerable  significance  when  associated  with  the 
other  factors.     Swelling  can  nsually  be  determined  by  palpation  over 
tbe  anterior  aspect  of  tlie  femoral 
neck  quite  early  in  tbe  joint  in- 
volvement. 

Altbough  all  these  symptoms 
— ])ain,  painful  spots,  swelling  on 
tbe  anterior  surface  of  joint,  and 
limitation  of  motion,  eitber  active 
or  ])assive — may  disappear  after 
rest  in  bed;  they  point  to  some 
definite  patbology. 

Diagnosis. — So  much  has  been 
written  on  this  phase  of  the  sub- 
ject that  passing  reference  only 
will  be  made  to  tbe  nontuberculous 
(ten  per  cent)  hip-joints,  of  which 
the  acute  infection  coxitides  in 
the  young  adult  offer  such  diffi- 
culties in  differentiation.  They 
are  usually  caused  by  the  Staphy- 
lococcus albus  or  aureus.  In  the 
history  the  point  of  systematic 
invasion  must  be  sought  after. 
Tbe  high  temperature,  the  acute 
onset,  the  sudden,  severe  pain, 
and  the  absence  of  ossific  change 
shown  by  the  Rontgen  ray  will 
usually  settle  the  diagnosis.  On 
several  occasions  tbe  writer  has 
been  able,  by  aspirating  the  hip- 
joint  with  a  long  needle  paral- 
lel to  tbe  femoral  neck,  to  se- 
cure synovial  fluid  containing  tbe 

staphylococcus,  the  Bacillus  typhosus,  or  tbe  streptococcus.  A  his- 
tory of  scarlet  fever,  measles,  or  gonorrhea  has  aided  in  the  differ- 
entiation. 

It  must  not  be  forgotten  that  almost  tbe  entire  symptomatology  of 
a  tul)('r(  iiU)Us  hi])-joint  7nay  be  simulated  in  hysteria. 

Treatment. — 'I'rcatmont  of  this  form  differs  only  from  that  of  other 
tubercular  joints,  because  (1)  of  the  weight  it  supports,  hence  rest  and 
extension;    (2)    securing   tbe   greatest   function   by   selecting   the   most 


Fig.    179. —  Multiple    Fistula    Open- 
ings OF  Tuberculous  Knee. 


748 


TUBERCULOSIS  OF   BONES  AND  JOINTS 


useful  position,  if  limitation  of  motion  occurs;    (3)    forbidding  use  of 
the  limb  until  all  tenderness  has  disappeared,  even  that  produced  by- 
blows  on  the  knee,  over  the  tro- 
chanters,   or    by    direct    pressure 
over  the  acetabular  rim. 

TUBERCULOSIS    OF    KNEE-JOINT 

The  general  description  of 
joint  tuberculosis  was  written  with 
the  knee-joint  in  mind,  hence  only 
data  of  special  interest  need  be 
mentioned.  It  is  more  frequent 
in  males  (ten  per  cent),  is  seen 
in  the  first  two  decades  of  life 
(fifty-five  per  cent),  with  trauma 
an  exciting  factor  (twenty  per 
cent).  The  knee  is  peculiarly 
adapted  to  the  formation  of  poly- 
poid growths,  hence  they  and  the 
rice  bodies  are  most  often  seen 
here.  The  latter  also  attain  an 
unusual  size.  Both  of  these  are 
more  easily  felt  in  this  joint  than 
elsewhere,  especially  over  the  con- 
dyloid margins,  with  the  joint 
held  at  right  angles. 

Atrophic  changes  occurring  in 
muscles  relatively  so  much  larger 
make  more  pronounced  the  spin- 
dle-shape of  a  tuberculous  knee  of 
prolonged  duration.  This  some- 
what characteristic  shape  is  not 
always  indicative  of  tuberculosis, 
however. 

In  the  early  stage  (hydrops) 
motion  is  usually  excellent;  dur- 
ing the  fungus  stage  it  is  the 
reverse,  even  passive  motion  be- 
ing restricted.  There  is  slight 
flexion,  with  outward  foot  rota- 
tion, with  final  backward  tibial  luxation.  In  so  large  a  joint,  supporting 
so  much  weight,  we  may  logically  expect  an  ultimate  mixed  infection 


Fig. 


180.  —  Plaster-of-Pari-s    Splint 
WITH  Fenestra. 


TUBERCULOSIS   OF   JOINTS  749 

because  ol'  tlie  constant  irritation  of  the  intlauied  surfaces,  deterniining 
the  lodgment  of  organisms  floating  in  the  blood  stream.  Indeed,  fifty 
per  cent  of  all  such  cases  become  thns  complicated,  rendering  the  prog- 
nosis more  grave.  Of  720  patients  observed  for  eighteen  years  by  Koenig, 
430  recovered,  with  useful  limbs,  but  only  11.7  per  cent  were  func- 
tionally perfect. 


CHAPTER   111 

PRIMAKY   TUBERCULOSIS    OF    MUSCLES    AND    FASCIA 
By  LEONARD  FREEMAN 

This  is  a  rare  affection,  Ijut  few  cases  having  been  reported,  al- 
though secondary  involvement  from  an  adjacent  focus — for  instance,  in 
the  glands  or  fascia — is  common  enough.  Primary  infection  takes 
place  through  the  blood,  and  usually  results  in  the  formation  of  a  cold 
abscess.  This  may  be  opened,  curetted,  and  drained ;  but  it  is,  perhaps, 
better  to  extirpate  the  diseased  tissue  completely,  if  this  can  be  done 
withoiit  sacrificing  the  muscle  to  too  great  an  extent. 

Tuberculosis  of  fasciae  is  frequently  associated  with  tuberculosis  of 
lymph  glands,  bones,  and  joints,  although  primary  infection  rarely  oc- 
curs. The  disease  is  difficult  to  eradicate  except  by  a  thorough  opera- 
tion, which  may  necessitate  the  extensive  removal  of  the  affected  fascia 
from  between  the  muscles  or  from  beneath  the  skin.  Treatment  by 
Bier's  passive  hyperemia  may  be  tried  in  suitable  cases,  as  may  also 
vaccination  with  tuberculin,  according  to  Wright. 
750 


CHAPTER  IV 

TUBERCULOSIS    OF   THE   BEAIX   AXD   ITS   MEMBRANES 
By  L.  L.  McARTHUR 

THE    MENINGES 

Until  within  a  very  few  years,  meningeal  tuberculosis  was  con- 
sidered as  an  incurable  affection  wholly  within  the  province  of  the 
internist.  That  there  begins  to  be  doubt  as  to  the  accuracy  of  this 
view  is  partly  due  to  tlie  revelations  which  surgery  has  made  in  the 
cure  of  similarly  affected  serous  membranes  elsewhere,  partly  to  the 
few  but  authentic  cures  Avhich  surgical  intervention  has  brought  about. 

Here,  as  elsewhere,  invasion  is  almost  invariably  through  the  circu- 
lation, since  the  bony  vault  protects  so  well  against  direct  infection  that 
extension  to  the  membranes  by  contiguity  is  the  rare  exception.  This 
being  true,  there  follows,  as  a  corollary,  the  existence  elsewhere  in  the 
body  of  a  tuberculous  process.  It  is  a  clinical  fact  that  over  four  fifths 
(eightA'-three  per  cent)  of  all  cases  occur  during  the  first  five  years 
of  life"! 

Until  recently  the  surgeon,  for  practical  purposes,  classified  menin- 
gitis into  two  general  classes:  (1)  the  tuberculous  and  (2)  the  non- 
tuberculous.  The  diagnosis  made,  he  has  been  too  content  to  rest :  but 
aggressive  interference  in  cases  heretofore  regarded  as  hopeless  has  given 
some  encouragement  for  the  future  (Duret).  Though  the  anatomic 
differences  between  tuberculous  and  the  nontuberculous  meningitis  are 
quite  definite,  the  clinical  differences  are  not  always  sufficiently  definite 
for  easy  diagnosis. 

Diagnosis. — With  the  recent  advancements  in  laboratory  methods, 
the  nontul)orculous  cases  can  be  separated  from  the  tuberculous. 

Symptoms. — The  s3^mptomatology  of  meningitis  being  wholly  de- 
pendent on  the  irritation  of  the  inclosed  nerve  tissue,  there  is  no  single 
pathognomonic  symptom.  Quincke's  lumbar  puncture  has  enabled  us 
to  disregard  many  symptoms  common  to  all  meningitides,  as  well  as  to 
detect  those  running  an  almost  symptomless  course  (Zappert  says 
sixty-six  per  cent).  A  normal  cerebrospinal  fluid  should  contain  no 
cellular  elements.    In  tuberculous  meningitis  lymphocytes  are  prevalent, 

751 


752        TUBERCULOSIS   OF   THE   BRAIN   AND   ITS  MEMBRANES 

more  especially  in  the  later  stages;  in  the  very  early  the  polynuclears 
prevail.  This  is  the  end  result  of  many  observations,  and  thus  limits  the 
value  of  the  cytodiagnosis  taken  alone. 

In  the  majority  of  cases  (seventy  per  cent)  the  tubercle  bacillus  can 
be  found  in  the  fluid.  Failure  to  find  the  organism  with  the  micro- 
scope may  require  inoculation  to  be  positive.  The  agglutination  tests 
of  Arloing  are  not  constant,  but  when  positive  are  valuable  as  confirma- 
tory evidence.  Moreover,  the  extent  of  the  lesion  bears  no  regular  re- 
lation to  the  severity  of  the  symptoms. 

Three  cardinal  symptoms  attend  a  meningitis:  Headache,  vomiting, 
and  constipation. 

Continuous  and  distressing  headache,  accompanied  by  vomiting  with- 
out indiscretion  in  diet,  explosive  in  character,  with  little  or  no  nausea, 
and  associated  with  an  obstinate  constipation,  is  the  usual  status  found. 

Ballance  adds  to  this  two  groups,  those  presenting  {a)  symptoms  of 
fever  and  impaired  nutrition;  {h)  symptoms  which  are  the  clinical  ex- 
pression of  the  irritation  of  the  subjacent  cortex.  These  are:  (1) 
Psychic;  (2)  motor;  (3)  sensory;  (4)  vasomotor,  and  (5)  tho.se  due  to 
destructive  action  on  nerve  cells.  Under  these  headings  would  come  irri- 
tability, disturl)ance  of  sleep,  cri  cerebral,  headache,  vomiting,  Kernig's 
sign,  ocular  or  facial  paresis,  rise  of  temperature,  slowed  pulse,  stiff 
neck,  etc. 

In  most  cases  of  tuberculous  meningitis  the  onset  is  insidious,  rarely 
fulminating.  In  location,  chiefly  involving  the  basal  membranes,  it  may 
extend  to  the  vertex,  or  be  localized  to  a  given  area,  producing  positive 
localizing  symptoms.  Its  duration,  varying  from  seven  to  fourteen  days 
on  the  average,  may  extend  to  several  weeks. 

The  exudate  is  of  grayish-yellow  color,  with  scattered  nodules,  the 
basal  nerves  being  ensheathed  therein.  The  membranes  of  the  Sylvian 
fissure  are  similarly  infiltrated,  the  cerebrospinal  fluid  is  increased  in 
quantity,  the  ventricles  dilated,  and  their  spendyma  showing  miliary 
bodies.  Thickening  of  the  latter  may  be  sufficient  to  occlude  their  exit. 
It  is  rarely  found  in  the  form  of  a  tuberculous  abscess.  Such  infectious 
diseases  as  whooping  cough,  measles,  etc.,  prove  favoring  factors. 

Treatment. — So  extremely  fatal  has  this  disease  been  regarded  in  the 
past,  that  the  diagnosis  made,  interest  and  activities  on  the  part  of  the 
medical  men  ceased.  Eealizing  that  the  dangers  of  the  disease  have  in 
no  wise  diminished,  the  siirgeon  has  come  to  understand  that  here,  as  in 
the  similarly  desperate  conditions — e.  g.,  of  general  peritonitis — a  certain 
small  percentage  of  cases  can  be  saved  by  heroic  measures.  In  less  severe 
cases,  less  radical  procedures  offer  some  hope  where  heretofore  there  was 
none. 

Ballance  has  called  attention  to  the  fact  that  loo  frequently  in  the 


THE   MENINGES  753 

past  tlic  sur^ieal  ett'orts  lo  check  a  meningitis  have  ceased  ■with  drainage 
of  the  dura,  though  the  tuherculous  disease  involves  the  pia  and  the 
subarachnoid  spaces.  Such  surgery  he  compares  to  drainage  of  tlie  pleura 
for  pericardial  effusion.  Hence,  the  Sylvian  lake,  the  ventricles,  the  basal 
areas,  or  the  spine,  should  be  drained  when  proper  indications  exist. 
While  the  conditions  differ  (because  of  many  added  factors  of  danger) 
from  those  of  tuberculous  peritonitis,  still  something  may  be  hoped  for 
from  proper  surgical  interference. 

While  not  an  advocate  of  operative  interference  in  every  tuberculous 
meningitis,  nor  of  drainage  through  and  through  with  lavage  of  the  cavi- 
ties bathed  by  the  cerebrospinal  fluid,  the  writer  is  convinced  that  the 
withdrawal  of  the  excessive  quantity  (10  to  30  c.c.)  either  by  spinal 
puncture,  trephine  openings,  or  ventricular  tappings  may,  by  the  reduc- 
tion of  cranial  pressure  and  by  the  escape  of  infective  elements,  prove 
the  turning  point  in  an  otherAvise  fatal  case.  Indeed,  cases  begin  to  ac- 
cumulate that  have  been  saved  by  such  methods.  Surgery  as  applied  to 
any  given  case  should  at  least  be  considered,  and  then  only  rejected  when 
the  local  or  general  conditions  render  all  efforts  futile.  It  not  infre- 
quently happens  that  a  meningitis  is  but  the  terminal  stage  in  a  hope- 
less lung,  peritoneal,  or  bone  tul)erculosis. 

Intervention  here,  as  elsewhere,  must  be  based  on  the  conditions  pres- 
ent. When  there  exists  a  localized,  circumscribed  meningeal  tuberculosis, 
with  definite  focal  symptoms,  operative  interference  offers  the  only  radi- 
cal means  of  betterment.  Again,  in  accidental  changes  incident  to  a 
healed  circumscribed  tuberculosis,  this  surgical  removal  may  prolong  life, 
or  improve  the  ]iatient's  condition.  As  in  the  pleura  or  peritoneum,  so 
here  the  tuberculous  irritation  of  the  serous  membranes  results  not  in- 
frequently in  excessive  fluid  exudate,  the  presence  of  which  soon  results 
in  destructive  changes  in  the  nerve  tissue  pressed  on.  Here  mechanical 
means  offer  the  onh-  practical  hope — hence  the  spinal  aspiration  of 
Quincke  becomes  a  therapeutic  measure. 

Unfortunately,  the  disease  in  nearly  half  the  cases  results  in  an 
occlusion  of  the  iter  a  tertio  by  an  involvement  of  the  choroid  plexuses; 
hence  intracranial  pressure  cannot  always  be  thus  reduced.  We  are  then 
compelled  to  employ  cranial  drainage  in  one  of  several  Avays.  In  the 
bal)e,  tapping  the  venti-icles  through  the  lateral  angles  of  the  fontanelle; 
in  those  requiring  it  a  trephine  opening  with  extracranial  drainage,  after 
the  author's  method,  or  subdural  drainage  after  Ballance,  has  given  bene- 
ficial results.  This  emphasizes  the  fact  that  we  have  a  chronic  diffuse, 
as  well  as  an  acute  tuljerculous  meningitis.  To  the  former  group  most 
cases  of  hydrocephalus  belong. 

To  reduce  the  pressure  from  the  accumulated  fluids,  Ballance  has 
recently  recommended  the  suspension  of  a  small  right-angled  tube  from 


754        TUBERCULOSIS   OF   THE   BRAIN   AND   TFS   MEMBRANES 

the  (liiral  iiieiubrane,  one  end  of  the  tube  being  inserted  into  the  hiteral 
ventricle,  the  other  remaining  subdural,  thus  converting  an  internal  into 
an  external  hydrocephalus.  The  writer  devised  years  ago  an  almost 
identical  procedure,  the  chief  difference  being  that  the  tube  was  flanged, 
the  flange  resting  on  the  external  surface  of  the  parietal  bone,  through 
which  a  drill  had  made  a  perforation  just  large  enough  to  permit  of  its 
jiassage  into  tlie  ventricle.  By  this  means  the  fluids  escaped  into  the 
cellular  tissues  I)eneath  the  scalp,  causing  an  edema  of  the  same,  slowly 
and  gradually  relieving  the  pressure,  and  benefiting  the  patient,  with 
less  chance  of  displacement  of  the  foreign  body.  Mikulicz  reported  sev- 
eral cases  treated  by  this  method.  Spontaneous  cures,  though  rare,  have 
been  observed. 

Laboratory  examination  of  the  fluids  removed  by  any  of  these  meth- 
ods have  proved  the  desirability  of  the  procedure,  since  infective  elements 
and  their  toxic  products  are  thus  eliminated.  Moreover,  cytologic  exam- 
inations and  inoculations  have  demonstrated  some  curable  forms,  while 
yielding  confirmatory  evidence. 

THE    BRAIN 

Tuberculomas  {Soli tan/  Tubercles) — those  large,  usually  solitary 
masses  of  tuberculous  matter  composed  of  nodes  undergoing  character- 
istic degenerative  changes — are  found  embedded  generally  in  the  nervous 
tissue.  They  have  their  origin  always  in  the  meninges,  a  fibrous  strand 
form  which  can  almost  invariably  be  demonstrated.  They  may  be  mul- 
tiple (twenty  per  cent).  Although  multiple,  one  tumor  alone  may  pro- 
duce symptoms,  the  others  being  "  latent "  or  in  "  negative  "'  zones. 
They  may  attain  the  size  of  an  orange.  They  rarely  follow  surgical 
tuberculosis,  and  are  of  very  slow  growth.  In  their  growth  they  press 
apart  the  adjacent  nerve  structures,  have  but  little  intimate  connection 
with  them,  and,  when  producing  localizing  symptoms,  have  been  success- 
fully removed,  the  patients  living  one,  two,  four,  six,  and  even  eight 
years.    They  occur  more  frequently  in  the  cerebellum. 

Alessaudri  reports  twenty-one  cerebral  and  five  cerebellar  tuberculous 
tumors  operated  on  with  rather  favorable  results  in  the  cerebral  cases. 
Greater  fatality  attends  the  cerebellar  tumor,  due  to  (1)  late  interfer- 
ence; (2)  deep  situation;  (3)  undeveloped  technic. 

They  produce  symptoms  common  to  all  V)rain  tumors  (headache, 
papillary  edema,  choked  disk)  ;  they  may  also  produce  focal  symptoms; 
and  in  addition  they  will  probably  show  a  reaction  to  either  Calmette's, 
V.  Pirquet's,  or  Wright's  tests  for  tuberculosis. 

While  presenting  in  their  clinical  history  or  physical  examination 
evidences  of  other  healed  or  active  tubercular  foci,  the  less  marked  the 


T1IJ-:   BRAIN  755 

general  pressure  symploms,  the  more  sure  the  local  diagnosis.  Too  niueli 
emphasis  cannot  be  laid  on  the  significance  of  the  early  appearance  of  the 
focal  symptoms,  but  in  the  absence  of  all  localizing  symptoms  the  tumor 
probably  occupies  one  of  the  negative  zones — e.  g.,  right  frontal  corpus 
striatum,  lenticular  nucleus,  anterior  portion  of  the  optic  thalamus,  or 
cerebellar  hemisphere. 

What  has  been  said  of  the  brain  and  its  mendjranes  liolds  true  of  the 
spinal  cord  and  its  coverings.  In  most  cases  of  spinal  tuberculosis  the 
disease  is  an  extension  from  above.  About  sixty-five  cases  have  been 
collected  in  Avhich  it  was  localized  in  the  cord.  When  so  localized  the 
symptoms  are  dependent  on  the  parts  involved.  A  tuberculoma  here 
produces  similar  pressure  symptoms  to  those  of  any  other  tumor,  and 
when  its  presence  can  be  diagnosed,  offers  greater  hope  of  benefit  than 
the  tumors  more  commonly  found  in  this  region. 


CHAPTER   V 

IXTE8TINAL    TUBEKC  UL08 J  S 
By  L.  L.  McARTHUR 

General  Considerations. — Intestinal  infection  l)y  the  tubercle  bacillus 
is  now  so  well  recognized  that  discussion  is  limited  to  when,  liow,  or 
why  it  occurs,  and  the  influence  of  treatment  on  it.  In  commencing 
the  study  of  intestinal  tuberculosis  we  are  confronted  at  once  by  the 
natural  subdivisions  pathologists  make,  based  on  their  findings. 

I.  Primary  Intestinal  Tuberculosis. 

II.  Secondary  Intestinal  Tuberculosis. 

With  many  thousands  of  autopsies  and  hundreds  of  observers  to  con- 
firm the  observations,  it  has  been  demonstrated  that,  while  the  vast  ma- 
jority of  cases  of  intestinal  tuberculosis  are  secondary,  there  are  quite  a 
number  of  cases  of  true  primary  intestinal  tuberculosis  without  other 
discoverable  lesion.  With  the  reopening  of  the  question  as  to  the  atrium 
of  infection  in  the  individual,  the  later,  more  painstaking  observations 
show  that  through  the  intestinal  tract  a  far  larger  proportion  (twenty- 
one  per  cent)  of  cases  occur  than  had  been  deemed  possible. 

A  definition  of  the  term  "  primary  "  should  here  be  given.  Several 
years  ago  the  writer  stated  that  it  is  impossible,  clinically,  to  predict  the 
location  of  the  absolute  primary  focus,  and  call  that  "  primary  "  which 
is  the  apparent  site  of  inception  of  the  disease.  Thus  an  orchitis,  a 
Pott's  disease,  or  hip  disease  may  clinically  be  primary,  while  the  post- 
mortem findings  prove  them  secondary  to  some  focus  in  a  mediastinal 
or  cervical  lymph  gland  or  other  unsuspected  area.  The  term  primary 
must  now  be  limited  to  those  cases  in  which  there  is  no  other  recogniz- 
able lesion  from  which  the  infection  could  rationally  have  occurred.  The 
number  thus  to  be  classified  is  constantly  increasing,  while  the  number 
of  cases  of  general  tuberculosis  in  which  the  atrium  of  infection  Avas  the 
intestinal  tract  exceeds  present  belief.  It  will  thus  be  seen  that  true 
primary  intestinal  tuberculosis  must  be  due  to  direct  infection  of  that 
tract  by  the  ingestion  of  tuberculous  foci,  while  the  secondary  occurs 
from  the  deglutition  of  infective  matter  coming  from  simihir  active 
processes  above,  in  the  same  individual. 

Practically,  babes  long  at  the  breast  and  milk-fed  infants  are  the  only 
756 


GENERAL   CONSIDERATIONS  757 

ones  afflicted  with  true  primary  intestinal  tuberculosis,  sinci;  the}'  are 
the  ones  exposed  to  the  most  commonly  infected  foods,  and  their  in- 
testinal tract  is  least  resistant  to  such  invasion.  While  both  Eisenhardt 
and  Fenwick  found  only  1  case  in  1,000  autopsies  on  adults  which 
they  considered  primary,  they  also  demonstrated  by  the  same  series  that 
few  cases  of  tuberculosis  of  the  respiratory  tract  escape  an  ultimate 
secondary  intestinal  tuberculosis.  Eisenhardt  in  his  1,000  autopsies 
of  tuberculous  adults  found  503  cases  wath  intestinal  infection;  489  had 
cavities  and  74  had  none.  Indeed,  the  intestinal  lesion  is  usually  over- 
shadowed by  the  pulmonary  disease.  But  inasmuch  as  the  presence  of 
cavities — and,  therefore,  bacilli  in  the  sputum  swallowed — determines  so 
regularly  the  intestinal  infection,  the  absence  of  cavity  formation  w^ill 
have  a  decided  prognostic  value  in  those  cases  coming  to  the  surgeon  for 
aid.  These  persons  will,  as  a  rule,  be  over  twenty-five  years  old,  and  more 
often  males  than  females. 

From  the  painstaking  monograjjli  of  Fiirst  one  can  secure  a  com- 
plete resume  of  all  the  arguments  for  and  against  the  intestinal  tract 
as  the  primary  route  of  infection  in  tuberculosis.  The  occurrence  of  intes- 
tinal tuberculosis  being  admitted,  there  is  need  for  a  clear  understand- 
ing of  how,  where,  and  why  this  happens.  Fiirst  tabulates  the  various 
modes  by  which  the  human  being  may  become  infected  with  tuberculosis, 
as  follows:  (1)  Aerogenous;  (2)  enterogenous;  (3)  amygdalogenous ; 
(4)  lymphogenous  or  hemogenous;  (5)  dermogenous;  (G)  hereditary 
and  congenital.    Of  these  the  first  two  are  of  special  interest. 

Aerogenous. — The  respiratory  tract,  so  universally  accepted  in  the 
past  as  the  principal  route  of  invasion,  has  of  late  been  proved  by  ex- 
periment, by  clinical  observation,  and  by  postmortem  findings  not  to 
infrequently  be  enterogenous  in  origin  {vide  Baumgarten's  cases  and 
experiments). 

Recently  there  has  arisen  almost  an  antithesis  in  the  belief  held 
for  the  twenty-three  years  following  the  reports  of  Koch  and  Baum- 
garten  of  their  discoveries,  as  to  the  infectivity  of  the  milk  of  tuber- 
culous cows.  This  is  consequent  on  the  reopening  of  the  question  by 
Koch  himself,  and  the  apparent  assumption  by  him  of  a  diametrically 
opposite  view  to  the  one  first  held.  I  say  apparent,  because  he  does 
not  deny  what  he  formerly  claimed  to  have  demonstrated,  but  he  insists 
that  the  transference  of  the  bovine  type  of  infection  to  the  human  being 
is  of  far  less  frequency  than  he  had  taught. 

Though  the  identity  of  the  human  with  the  bovine  tuliercle  bacillus 
had  been  universally  accepted,  Koch's  London  address  threw  a  shadow 
of  doubt  over  the  matter.  There  has  been  a  division  of  scientists  into 
two  groups,  with  Koch  heading  the  dualists.  Even  the  dualists  hesi- 
tate to  advocate  the  abandonment  of  all  those  precautionary  inspections 


758  INTESTINAL  TUBERCULOSIS 

of  meats,  milks,  and  animal  foods  for  wliicli  every  government  lias  made 
such  splendid  provision  in  their  bureaus  of  animal  industries.  The  in- 
numerable reseai'ches  and  reinvestigations  stimulated  by  this  reopening 
of  the  question  have  demonstrated  the  intimate  relationship  between  the 
two  organisms,  and  have  proved  the  ])0ssibility  of  enterogenous  infection 
with  the  bovine  organism,  which  is  distinguished  by  the  term  "pearl" 
bacillus,  l)ecause  it  induces  "  Perl  such  t  " — l)ovine  tuberculosis. 

rt  is  at  postmorl(Mn  examinations  that  the  greatest  surprises,  the 
strongest  confirmations,  the  surest  evidences  of  the  atrium  of  primary 
infection  manifest  themselves.  They  furnish  us  with  our  most  positive 
]u-oofs  as  to  the  varying  modes  of  invasion.  In  this  disease  the  pathol- 
ogist can  frequently  determine  which  is  the  older  and  which  is  the  more 
recent  process.  Cicatrices,  calcifications,  encapsulations,  and  adhesions 
are  evidences  of  the  older  process,  while  the  miliary  bodies  and  acute 
inflammatory  processes  are  of  more  recent  origin.  These  pathologic 
anatomic  findings  give  indubitable  proofs  that  figures  alone  must  con- 
vince us  that  the  enterogenous  infection  is  not  only  possible  but  proved. 

Often  an  autopsy  held  on  children  dead  of  measles,  scarlet  fever,  or 
diphtheria,  has  revealed  an  unsuspected  tu])erculosis,  while  affording  a 
convincing  proof  of  both  the  site  of  the  primary  invasion,  and  after  that, 
equally  instructive  evidences  of  its  latency,  duration  of  virulency,  or 
spontaneous  healing. 

The  painstaking  investigations  of  Kossel,  Nageli,  Heller,  and  v. 
Hansemann  have  given  the  astonishing  result  that  every  second  or  third 
individual  has,  at  some  time  in  his  life,  accjuired  and  recovered  from 
a  tuberculous  infection.  This  without  its  having  ever  been  suspected 
or  detected.  But  these  evidences  have,  by  their  site  and  solitary  char- 
acter, demonstrated  beyond  cavil  the  door  of  entrance;  for  example,  the 
finding  of  solitary  caseous  hmiph  glands  in  the  mesentery  beyond  the 
cicatrix  of  a  healed  intestinal  ulcer,  but  without  other  discoverable  forms, 
is  proof  of  a  primary  enterogenous  infection. 

A  review  of  the  records  of  autopsies  made  (as  was  done  by  Fiirst) 
shows  a  great  variation  in  the  presence  or  absence  of  tuberculosis,  but 
I)y  eliminating  all  probabilities  of  error,  and  accepting  only  the  most 
conservative  estimates  as  to  frequency,  it  is  very  evident  that  in  every  100 
postmortems  held  on  children  dead  from  whatever  cause,  29  or  30  deaths 
have  been  from  tuberculosis. 

Frequency. — During  the  first  three  months  of  life  intestinal  tubercu- 
losis has  scarcely  ever  been  observed.  In  446  postmortems  held  from 
1<S92  to  1902,  Trepinsky  failed  to  find  a  single  case  in  the  first  four  weeks, 
but  found  one  in  the  fifth  to  the  ninth  week.  From  the  third  month  to 
the  third  year  there  was  a  rapid  increase  in  frequency,  diminishing  again 
from  the  fifth  to  the  tenth  year.    Nearly  half  the  children  dissected  dur- 


ENTEROGENOUS  759 

iiig  the  first  five  years  of  life  were  found  to  be  tuberculous.  He  lias  also 
shown  by  a  composite  report  of  fifty  competent  pathologists  that  the 
frequency  of  infection  through  the  respiratory,  as  compared  with  the 
alimentary  tract,  is  greatest  in  children :  Under  two  years,  as  9  to  5 
(Symes  and  Fischer,  based  on  oldest  forms)  ;  two  to  twelve  years,  as 
4.71  to  1 ;  thirteen  to  twenty-four  years,  as  3. ST  to  1 ;  twenty-five  to 
thirty-six  years,  as  0.06  to  1.  ^^^lile  these  figures  show  flie  relative 
frequency  of  the  ])rocess,  they  do  not  demonstrate  the  primary  character 
of  intestinal  tuberculosis. 

While  conceding  the  great  preponderance  of  the  aerogenous.  amyg- 
dalogenous,  and  lymphogenous  mode  of  infection,  4.5  per  cent  of  primary 
intestinal  invasion  is  none  the  less  significant.  It  having  l)een  demon- 
strated (Ribbert,  Orth,  Spengler)  that  primary  bronchial  lymph-gland 
tuberculosis  does  occur  without  pulmonary  involvement,  the  parallel 
possibility — primary  mesenteric  tuberculosis — seems  equally  possible.  In- 
deed, Freisich  and  Schulz  have  come  to  the  conclusion  that  bronchial 
lymph-gland  tuberculosis  is  not  necessarily  proof  of  respiratory-tract 
infection,  and  Behring  claims  that  the  primary  character  of  pulmonary 
invasion  is  very  much  overestimated.  Such  extreme  views  as  Branden- 
burg's, that  "  for  pulmonary  tuberculosis  the  intestinal  source  of  infec- 
tion is  the  most  frequent,"  cannot  yet  be  accepted  as  proved.  Since 
Baumgarten  has  demonstrated  that  pulmonary  tuberculosis  can  be  in- 
duced through  the  uninjured  urinary-tract  mucosa,  it  is  easy  to  conceive 
how  the  same  thing  may  occur  in  the  intestine.  Finally,  it  can  easily 
be  comprehended  how  infective  organisms,  gaining  access  to  the  upper 
respiratory  passages,  may  be  arrested  by  the  mucus,  which,  being  swal- 
lowed, may  induce  an  enterogenous  infection   (Buttersack). 

Enterogenous. — The  mere  question  of  a  primary  enterogenous  infec- 
tion is  of  little  moment  if  we  fail  to  consider  the  question  whether  a  food 
infected  with  bovine  tuberculosis  can  produce  tuberculosis  in  the  human 
being.  Can  milk  from  tuberculous  cattle  produce  the  disease?  When 
Koch,  a  quarter  of  a  century  ago,  announced  the  discovery  of  the 
tubercle  bacillus,  he  also  suggested  the  great  probability  of  danger  of 
infection  from  tuberculous  animals.  This  suggestion  resulted  in  the 
systematic  prophylactic  examination  of  animals  sold  for  food,  their  milk 
and  its  products.  To-day  he  leads  the  opposition  to  this  view,  arguing 
that  the  bovine  organism  rarely  induces  tuberculosis  in  human  beings. 
Investigations,  experimental  and  clinical,  made  since  1901  show  that  this 
is  not  only  possible,  but  probable.  The  instances  quoted  are  isolated ; 
still,  the  observers  reporting  them  base  their  opinions  on  carefully  studied 
cases.  * 

Fiirst  collected  and  tabulated  the  reports  of  1(50  undeniable  ])rimary 
intestinal  tuberculous  cases,  some  of  which  seemed   indubitably  due  to 


760  INTESTINAL  TUBERCULOSIS 

tlie  l)oviue  bacillus.  He  submits  tbe  liistories,  nature  of  lesions,  nnd 
postmortem  findings  of  some  30  other  cases  which  he  classifies  as  prob- 
ably primary,  but  not  proved,  with  a  third  group,  of  '^3  cases,  of  general 
tuberculosis  whose  origin  appeared  to  be,  in  the  opinion  of  the  pathol- 
ogist, from  a  primary  intestinal  focus.  Baumgarten  demonstrated  that 
the  tubercle  bacillus  can  and  does  pass  through  the  intact  intestinal 
mucous  membrane  to  be  arrested  in  the  mesenteric  lymph  glands.  Ee- 
sistance  to  infection,  however,  must  indeed  be  great,  or  the  frequency  of 
intestinal  invasion  in  consumptives  should  exceed  even  the  50.3  per  cent 
demonstrated  by  Eisenhardt.  While  the  germicidal  action  of  the  di- 
gestive juices  protects  the  adult  against  infection,  in  the  child  this 
action  is  not  always  active  or  present ;  hence  the  greater  frequency  in 
children  of  infection  through  this  route.  Simple  ulcers,  too,  under  these 
conditions,  easily  become  the  seat  of  infection ;  hence  a  simple  ap- 
pendiceal, typhoid,  or  other  lesion  becomes  infected  with  tuberculosis. 
Again,  the  lymph  follicles  of  the  intestine  permit  the  passage  of  these 
organisms,  for  the  pathologist  has  found  tul)er(ulous  mesenteric  glands, 
tuberculosis  of  the  chyle  cistern,  tu])erculosis  of  the  subclavian  artery,  of 
the  right  heart,  and  even,  with  normal  bronchial  glands,  a  pulmonary 
tuberculosis,  as  an  end  result  of  an  intestinal  tuberculosis. 

Statistics  demonstrate  the  atrium  of  entrance  in  many  an  intestinal 
(and  lung)  tuberculosis  to  have  been  through  the  mucosa.  Lubarsch 
claims  that  there  is  primary  intestinal  tuberculosis  in  21.2  per  cent  of 
all  autopsies  on  tuberculous  individuals,  and  in  4.7  per  cent  of  all 
children  coming  to  autopsy.  Hof,  by  adding  the  undoubted  cases  of 
primary  mesenteric  tuberculosis  to  the  others,  puts  this  figure  in  the 
case  of  tuberculous  children  at  25.1  per  cent. 

From  the  following  table  it  will  be  seen  that  while  in  two  thirds  of 
the  cases  the  invasion  occurs  through  the  respiratory  tract,  the  next  im- 
portant atrium  lies  somewhere  in  the  intestinal  tract. 


Respiratory 

Alimentary 

Carr '. 

75.2% 

59% 

56.2% 

55.9% 

34.6% 

19% 

Kossel . .    .    .                   

4.5% 

Hof ...        .                        

25.1% 

Still . .        .                           

25.5% 

Nebelthau 

19.2%, 

Average 

56% 

18.6% 

Two  observations  may  here  be  referred  to  appropriately:  (a)  The 
experiments  of  Welseminsky  and  Basch,  who  proved  the  rapidity  of 
the  spread  of  the  bacilli  when  introduced  into  the  circulation,  show 
that  within  a  few  hours  the  bacilli  could  be  demonstrated  in  the  milk. 


ULCERATIVE  701 

(6)  Koger  and  Gamier  deinunstrated  the  existence  of  tubercle  bacilli 
in  the  milk  of  a  tuberculous  mother,  both  by  feeding  experiments  and 
by  postmortem  examination  of  her  child.  It  had  a  primary  mesenteric 
tuberculosis. 

Etiology. — It  may  be  said  that  the  deglutition  of  active  bacilli  is 
practically  always  the  cause,  and  we  are  indebted  to  Bollinger  for  the 
demonstration  that  tuberculous  food  can  induce  a  primary  intestinal 
tuberculosis,  even  through  an  absolutely  intact  mucous  membrane  (Do- 
broklonsky)  ;  and  Klebs  called  attention  to  the  s])utum  as  the  etiologic 
factor  of  moment  in  secondary  intestinal  tuberculosis. 

Any  processes  which  disturb  the  integrity  of  the  mucous  lining  of  the 
intestinal  tract  will  act  as  predisposing  factors ;  hence  diphtheria,  gastric 
or  duodenal  ulcer,  dysentery,  typhoid  ulcer,  colitis,  appendicitis  (et  id 
genus  omne),  are  occasionally  followed  by  such  mixed  infection.  The 
writer  has  personally  observed  such  implantation  on  a  gastric  ulcer,  on 
a  cholecystenterostomy  union,  and  on  the  site  of  a  simple  appendicitis. 
Disturbances  of  the  stomach,  Ijy  permitting  the  infective  elements  to 
escape  the  bactericidal  action  of  the  normally  acid  gastric  Juices,  are 
probably  more  important,  and  explain  the  rarity  of  tuberculous  gastric 
ulcers,  as  well  as  the  greater  frequency  of  invasion  in  the  young  child. 
The  mode  of  infection  reseml)les,  in  many  ways,  that  of  typhoid,  affecting 
usually  the  lower  ileum  and  ileocecal  region,  through  the  solitary  follicles 
or  lymph  glands,  since  it  is  lymphatic  tissue  chiefly  for  which  the  Iiacillus 
shows  its  predilection. 

As  in  the  passage  of  carbon  particles  through  the  intact  mucosa  of  the 
lungs,  by  entrance  into  the  lymph  stomata  on  its  surface,  perhaps  as- 
sisted by  the  ameboid  movements  of  the  phagocytes,  so  in  the  intestine, 
through  corresponding  stomata,  the  tubercle  bacillus  is  carried  to  the 
near-by  lymph  glands.  Thus  the  primary  lesion  will  be  seen  in  the 
lymph  glands  of  the  mesentery  without  a  corresponding  discoverable 
lesion  in  the  mucosa.  So  many  well-observed  instances  of  this  kind  have 
now  been  recorded  that  those  who  formerly  opposed  such  a  possibility 
now  freely  admit  that  the  primary  atrium  need  not  be  so  large  as  to  be 
discoverable  at  the  autopsy.  The  very  fact  that  this  is  possible  is  a, 
if  not  the,  determining  factor  as  to  which  of  the  varieties  of  intestinal 
tuberculosis  will  ensue,  for  the  mode  of  entrance  determines  the  patho- 
logic anatomy  of  the  case,  whether  of  the  (1)  ulcerative  or  (2)  hyper- 
trophic type. 

Ulcerative. — When  the  site  of  invasion  has  been  in  Peyer's  patches, 
or  in  the  solitary  follicles,  there  is  a  tul)erculous  infiltration  of  these 
structures  which,  following  the  usual  course  of  that  disease  elsewhere, 
soften,  casoate,  and  break  down,  with  ihe  resultant  characteristic  tuber- 
culous ulcer,  with  imdcniiiiu'd  edges.    These  ulcers  present  many  of  the 


762  INTESTINAL  TUBERCULOSIS 

tliaracteristics  of  typhoid  ulcers,  and,  like  them,  may  lead  to  hemorrhage 
or  perforation  (five  per  cent).  The  ulcers  are  multiple,  but  usually  not 
as  numerous  as  in  typhoid.  There  exists  a  predilection  for  the  extension 
of  the  tuberculosis  process  in  the  course  of  the  blood  and  lymph  vessels; 
hence  they  lie  transverse  to  the  long  axis  of  the  gut,  and  when  showing 
(rarely)  a  tendency  to  heal,  induce  a  circular  stenosis  of  varying  degree. 
As  before  stated,  while  these  normal  anatomic  structures  form  the  usual 
site  of  invasion,  many  clinicians  have  observed  the  direct  implantation  of 
a  tuberculosis  on  a  simple  inflammatory  process,  such  as  appendicitis, 
catarrhal  colitis,  typhoid  ulcers,  etc. 

Hypertrophic  Variety. — When,  on  the  other  hand,  the  infection  has 
occurred  through  the  unbroken  mucosa  into  a  lymph  channel,  and  the 
infective  elements  become  arrested  in  the  submucous  lymph  glands,  these 
undergo  the  well-known  histologic  changes,  with  infiltration  of  the  serosa 
and  subserosa.  Together  with  this,  an  unexplained  but  very  constant 
phenomenon  is  observed — i.  e.,  instead  of  a  breaking  down  of  tissue,  an 
immense  deposit  of  fibrous  tissue  ensues,  with  very  few  miliary  bodies. 
Tumor  formation  occurs,  so  pronounced  as  sooner  or  later  to  be  discov- 
ered by  palpation.  Like  all  new  connective  tissue,  it  contracts  as  it  ages. 
In  its  contraction  there  results  the  stenosis  that  plays  so  important  a  role 
in  the  symptomatology  of  this  variety  of  tuberculosis.  For  anatomic 
reasons  this  stenosis  occurs  most  often  at  the  ileocecal  junction,  the  re- 
sulting tumor  requiring  careful  study  to  differentiate  it  from  other 
neoplasms  found  in  this  region. 

The  symptomatology  of  this  disease  varies  with  the  variety  under 
observation,  but  so  widely  as  often  to  escape  observation  until  autopsy, 
presenting  only  the  aspects  of  a  profound  anemia. 

In  the  ulcerative  form  there  may  and  usually  do  exist  the  symptoms 
common  to  chronic  intestinal  catarrh,  with  alternating  diarrhea  and  con- 
stipation. Ulcerated  surfaces,  bathed  continually  by  the  passage  of  in- 
testinal contents,  naturally  occasion  abdominal,  umbilical,  or  right  iliac 
pains,  often  colicky  in  character.  The  more  extensive  and  deeper  the 
ulcerations,  the  more  sensitiveness  is  there  of  the  overlying  peritoneal 
surfaces;  hence  tenderness  on  palpation  is  frequently  present.  Like 
typhoid  ulcers,  they  are  prone  to  bleed,  though  not  usually  to  the  point 
of  exhaustion.  Blood  can  generally  be  found  in  the  stools,  occult  in 
character  if  the  ulcers  are  few  in  number,  small  and  situated  high  up  in 
the  small  bowel,  because  mixed  with  the  stool;  evident,  bright,  and  coat- 
ing the  formed  stool  when  the  ulcers  are  situated  in  the  larger  bowel. 
Bamberger  calls  attention  to  the  sagolike  bodies  found  in  the  stools, 
that  are  really  broken-down  miliary  granules  from  the  follicles  and 
ulcer  bases,  in  which,  too,  are  to  be  found,  more  easily  than  elsewhere 
in  the  dejecta,  the  tubercle  bacillus. 


HYPERTROPHIC   VARIETY  76o 

Such  a  symptom-complex,  of  any  duration,  should  lead  the  observer 
to  suspect  the  presence  of  tuberculosis,  while,  at  the  same  time,  trying 
to  verify  his  suspicions  by  a  careful  search  for  the  bacillus,  as  well  as 
all  the  factors  which  enter  into  the  clinical  history  of  a  tuberculous  sub- 
ject. The  Mayos  have  shown  that  the  tubercle  bacillus  can  more  easily 
be  obtained  from  the  secretions  just  within  the  sphincters. 

Absorption  of  the  toxins,  here  as  elsewhere,  provokes  an  evening  rise 
in  temperature  of  varying  degree,  and  the  constitutional  disturbances  are 
similar  to  those  seen  in  tuberculosis  in  any  other  part.  When  the  ulcer- 
ative process  lies,  as  it  sometimes  does,  in  contact  with  the  parietal  wall, 
there  results,  as  Vocht  has  shown,  a  peculiarly  indurated  plaque,  the 
tuberculous  invasion  inducing  changes  identical  with  those  occurring 
in  the  intestinal  wall  in  the  hypertrophic  variety.  On  cutting  into  such 
a  plaque  for  the  first  time,  one  is  so  absolutely  nonplussed  to  find  in  the 
layers  of  the  oblique  muscles  and  peritoneum  such  a  flat  cartilaginous- 
like  body  that  he  may  doubt  his  own  powers  of  orientation.  Wocht's 
plaqiies  have  been  observed  over  the  ileocecal  region,  along  the  colon, 
and  in  Douglas's  pouch.  Tillmanns  also  mentions  having  observed 
them. 

In  either  variety  the  process  is  so  chronic  as  to  be  significant.  The 
ulcerative  variety  may  induce  adhesions  and  some  thickening,  but  the 
hypertrophy  characterizing  the  invasion  of  the  bowel  wall  from  the  serous 
side  is  absent.  The  ulcers  may  lead  to  fistulae,  abscesses,  and  perforative 
peritonitis;  hence  these  characterize  the  later  stages.  These  ulcers  show 
little  tendency  to  heal,  but  occasionally,  by  doing  so,  induce  sufficient 
stenosis  to  require  operative  intervention.  The  ulcerative  variety  is  most 
often  seen  with  an  active  tuberculous  process  elsewhere,  especially  in  the 
lungs,  while  in  the  hypertrophic  type  usually  no  other  active  process  can 
be  found.  So  closely  may  the  symptoms  in  the  more  extensive  cases 
resemble  appendicitis  that  Benoit  has  even  proposed  the  terminology 
for  the  two  types — (a)  neoplastic,  (h)  appendicitic. 

Objectively  the  hypertrophic  tuberculosis  resem])les  so  closely  the  con- 
ditions seen  in  malignant  growths  of  the  ileocecal  valve  that  many  cases 
heretofore  operated  on  and  reported  as  such  have  since  proved  to  be  cases 
of  hypertrophic  tuberculosis. 

In  brief,  then,  the  formation  of  a  tumor  at  the  ileocecal  junction, 
with  slowly  oncoming  stenosis,  characterizes  the  hypertrophic  variety. 
Macroscopically  the  tumor  consists  of  an  immensely  thickened,  hardened 
bowel  wall  af  tbo  ileocecal  region  or  below,  with  often  a  distended  and 
hypertropliicd  ileum  al)ove  and  an  atrophic  and  colla])sed  colon  beyond 
the  growlli,  due  In  tlie  stenosis,  which  makes  its  aj)pearance  much  later, 
relatively,  tliiiu  in  cancer.  Adhesions  of  varying  degree  form:  the  cor- 
responding mesenteric  lymph  glands  enlarge,  and  the  peritoneum  in  the 


764  INTESTINAL  TUBERCULOSIS 

neighborhood  of  or  covering  the  growth,  on  close  inspection,  shows  mil- 
iary tubercles. 

Location. — Great  unanimity  of  opinion  exists  as  to  the  seat  of  in- 
testinal tuberculosis  being  in  the  ileocecal  region  (eighty- five  to  ninety 
per  cent),  where  the  longer  contact  with  irritating  decomposition 
produces  the  firmer  consistencv,  the  angular  implantation  of  the  ileum 
and  its  peculiar  vascular  supply,  all  combine  to  diminish  resistance  and 
to  increase  the  trauma.  The  Peyer's  patches  and  solitary  follicles,  most 
numerous  in  this  area  and  which  in  the  adult  undergo  involution  changes, 
are  peculiarly  susceptible. 

Mere  tuberculous  nodules  and  granulations,  with  accompanying  in- 
volvement of  the  neighboring  lymph  tracts,  first  manifest  themselves, 
spreading  in  the  direction  of  the  intestinal  flow.  Czerny,  quoted  by 
Senn,  states  that  areas  of  ulceration  are  limited  to  one  side  of  the 
ileocecal  valve.  With  this  the  writer  is  not  in  accord,  having  seen 
ulcerations  both  above  and  below  the  valve.  The  stomach  is  practically 
immune  to  tuberculous  ulcer. 

Treatment. — The  treatment  of  intestinal  tuberculosis  is  both  medical 
and  surgical,  medical  only  so  far  as  the  ulcerative  variety  is  concerned, 
since  the  hypertrophic  variety  is  uninfluenced  by  medication.  When  the 
ulcerative  variety  has  failed  to  improve  after  a  reasonable  length  of  time 
under  such  hygienic  care  and  medication  of  the  alimentary  tract  as  the 
Judgment  of  a  competent  physician  would  dictate,  and  the  pulmonary 
process  is  demonstrated  to  be  not  so  active  as  to  contraindicate  all  surgical 
interference,  the  surgeon  should  intervene.  The  nature  of  that  interven- 
tion can  only  be  determined  after  the  nature,  extent,  and  location  of  the 
disease  has  been  demonstrated  In'  laparotomy,  and  the  physical  condition 
of  the  patient  has  l)een  considered.  In  general  it  may  be  stated  as  true 
that  this  class  of  cases,  more  than  any  other,  withstands  surgical  insult 
better,  and  that  these  patients  convalesce  more  smoothly  from  formidal)lc 
surgical  procedures;  hence  a  boldness  not  otherwise  permissible  may  be 
resorted  to. 

Surgical  intervention  will  consist  of  (1)  excision  of  the  diseased 
area,  or  (2)  its  exclusion.  Therefore,  when  the  lesion  is  found  in  a 
patient  who  otherwise  is  in  reasonably  good  condition,  and  when  the 
lesion  involves  either  the  last  twelve  or  eighteen  inches  of  ileum,  the 
ileocecal  region,  or  the  ascending  colon,  or  all  three,  complete  excision 
may  be  practiced  with  reasonable  hope  of  recovery  from  operation  and  a 
symptomatic  cure  of  the  patient. 

When  the  condition  of  the  patient,  for  various  reasons,  contraindi- 
cates  so  radical  a  procedure,  a  diversion  of  the  intestinal  cui-rent  I)y  ]iar- 
tial  exclusion  has,  in  the  author's  experience,  jtroved  an  ctlicient  measure. 
Putting  the  diseased  part  at  rest,  by  the  prevent  ion  of  t1)o  ])assagc  of  the 


TREATMENT  765 

intestinal  contents  over  the  surface  of  the  ulcerations,  will,  at  times, 
ameliorate  or  cure  the  local  processes,  and  restore  the  patient  to  ap- 
parent health. 

When  the  hypertrophic  variety  is  considered,  we  have  as  the  principal 
symptom  stenosis — slow,  gradual,  but  increasing  in  severity  until  finally 
mechanical  relief  must  be  afforded.  It  is  interesting  and  instructive  that, 
as  in  the  case  of  a  heart  suffering  from  valvular  stenosis,  there  is,  first, 
hypertrophy  above  to  compensate  for  the  gradually  obstructing  lesion,  to 
be  followed  by  a  sudden  dilatation  when  compensation  fails ;  so  in  the 
intestine,  the  first  urgent  symptom  may  be  the  sudden  appearance  of 
obstruction,  when  the  limit  of  compensatory  hypertrophy  above  the 
stricture  has  been  reached.  The  writer  has  more  than  once  been  called 
in  cases  of  suspected  appendicitis  with  tumor,  when  the  trouble  revealed 
itself  as  an  hypertrophic  stenosis  at  the  ileocecal  valve.  With  nothing  in 
the  condition  of  the  patient  to  contraindicate  it,  a  total  a1)lation  of  the 
ileocecal  region  has  been  practiced  with  gratifying  results.  When,  how- 
ever, the  stenosis  had  been  of  long  standing  so  as  to  have  greatly  emaci- 
ated the  patient,  with  consequent  fecal  vomiting,  exclusion  by  anastomosis 
has  given  perfect  results. 


CHAPTER   VI 

TTTBERCULOrS   ISCHIORECTAL  ABSCESS   AND   ANAL 

FISTULA 

By   LEONARD   FREEMAN 

It  has  been  estimated  that  fourteen  or  fifteen  per  cent  of  anal  fistulae 
occur  in  tnberciilous  individuals,  and  that  approximately  five  per  cent  of 
tliose  afflicted  with  phthisis  have  fistulae.  It  must  not  be  assumed,  bow- 
over,  that  because  a  fistula  occurs  in  a  consumptive  it  is  necessarily 
tuberculous.  There  is  no  reason  why  a  consumptive  sboubl  not  have 
a  simple  fistula  as  well  as  anyone  else,  and  perhaps  more  reason.  In 
other  words,  a  careful  distinction  is  necessary  between  "tuberculous 
fistul.T  and  fistube  in  the  tuberculous." 

Pathology. — Tuberculous  ischiorectal  a])seesses,  which  alwa3^s  precede 
the  formation  of  fistubT",  are  usually  due  to  infection  through  the  bowel, 
although  they  may  arise  from  the  prostate,  from  bone  lesions,  or  even 
from  local  traumatisms.  Although  much  has  been  said  in  favor  of  hem- 
atogenous origin,  nevertheless  the  intestinal  theory  has  been  accepted 
abnost  univei'sally.  Cliiari  has  offered  a  plausil)le  explanation  of  the 
manner  in  which  infection  occurs  by  calling  attention  to  certain  diver- 
ticula which  often  exist  in  the  mucous  membrane  just  above  the  anus, 
and  represent  abnormally  enlarged  lacunae  IMorgagnii.  They  are  em- 
bedded in  the  connective  tissue  surrounding  the  bowel,  and  may  pene- 
trate between  the  fibers  of  the  sphincter  muscle.  Fecal  matter  contain- 
ing tubercle  bacilli  and  other  microiirganisms  enters  these  lacunae,  and 
if  they  are  unusually  deep  and  the  drainage  poor,  inflammation  may 
result  and  communicate  itself  to  the  surrounding  ischiorectal  tissues, 
thus  giving  rise  to  an  abscess.  The  process  bears  a  strong  resemblance 
to  the  recently  described  "diverticulitis"  (Mayo)  which  has  been  ob- 
served in  the  region  of  the  sigmoid.  In  cases  of  pulmonary  phthisis, 
tubercle  bacilli  which  have  been  swallowed  with  the  sputum  may  easily 
find  lodgment,  and  it  may  be  that  contaminated  food  is  an  occasional 
carrier  of  the  germs. 

Symptoms  and  Diagnosis. — Tuberculous  ischiorectal  abscesses  are 
usually  more  or  less  indolent  in  character,  at  times  becoming  quite 
large  without  causing  a  great  amoimt  of  discomfort ;  but  occasionally 
766 


SYMPTOMS  AND   DIAGNOSIS  767 

they  are  acute,  with  marked  h)eal  and  general  syiii|)t()nis,  indicating  a 
mixed  infection  and  leading  to  much  uncertainty  in  diagnosis.  Tuber- 
culous tistultp  almost  invariably  occur  in  connection  with  pulmonary 
phthisis,  l)ut  they  are  never  the  cause  of  the  phthisis,  nor  do  they  in- 
fluence its  course  for  the  better  in  any  way.  They  may,  however,  react 
unfavorably  on  the  lungs  by  adding  new  and  debilitating  complications; 
and  it  is  not  unreasonable  to  suppose  that  the  annoyance  of  a  Ijad  fistula 
might  turn  the  scale  against  an  invalid  where  disease  and  resistance 
were  evenly  balanced,  as  is  so  often  the  case. 

The  appearance  of  the  cutaneous  mouth  of  a  tuberculous  fistula  is 
often  characteristic,  in  that  the  edge  of  the  opening,  which  is  usually 
large,  is  apt  to  be  undermined,  ragged,  and  livid  in  color,  but  this  is 
by  no  means  always  true. 

Ulceration  of  the  skin  frequently  exists,  together  with  "  fungous 
granulations,"  and  caseous  deposits  may  occasionally  be  detected.  The 
more  active  the  process  the  greater  the  tendency  toward  ulceration, 
which  may  be  very  extensive.  It  has  been  asserted  that  tuberculous 
fistulffi  are  never  surrounded  by  indurated  tissue  like  the  ordinary  fis- 
tula, which  is  suggested  as  an  aid  to  diagnosis.  The  trutli  is,  however, 
that  fibrous  thickening  is  as  common  here  as  it  is  in  tul)ereulosis 
elsewhere,  representing  the  reaction  of  the  part  against  bacillary  in- 
vasion. 

The  discharge  is  apt  to  be  scant  and  watery;  but  this  is  far  from 
pathognomonic,  as  the  secretions  from  simple  fistulne  may  be  of  this 
character,  and  in  mixed  infections  with  a  tuberculous  basis  profuse 
suppuration  may  exist. 

The  indolence  of  the  original  abscess,  together  with  a  comparative 
absence  of  pain  and  tenderness,  is  always  suggestive  but  not  conclusive, 
and  the  same  may  be  said  of  the  presence  of  tuberculosis  elsewhere, 
especially  in  the  lungs.  Some  waiters  lay  much  stress  on  the  absence 
of  fat  in  the  ischiorectal  fossa,  the  laxity  of  the  sphincter  muscle,  and 
tlu!  presence  of  a  superabundance  of  long,  silky  hair;  but  these  condi- 
tions belong  more  to  pulmonary  consumption  in  general  than  to  tuber- 
culous fistula?  in  particular,  and  may  be  present  when  the  fistula  is  a 
simple  one. 

The  demonstration  of  Koch's  bacillus  is  difficult,  as  in  most  surgical 
tuberculoses,  and  its  apparent  absence  should  not  have  too  much  influ- 
ence on  the  diagnosis.  The  inoculation  of  guinea  pigs  with  the  dis- 
charge is  more  reliable,  but  it  requires  too  much  time  and  trouble  to  be 
employed  frequently. 

It  can  be  understood  from  the  above  that  many  fistuUv  cannot  be 
recognized  as  tuberculous  until  after  operation,  when  the  Avound  refuses 
to  heal  in  the  ordinary  manner.     Hence,  it  may  be  best  to  treat  every 


768     TUBERCULOUS  ISCHIORECTAL   ABSCESS  AND  ANAL   FISTULA 

fistula  in  a  consumptive  as  thoui,'li  it  \ver<'  due  to  the  tulterde  hacillus. 
thus  saving  time  and  avoiding  many  disappointments. 

Treatment. — Anal  fistula  was  one  of  the  first  surgical  diseases  to 
receive  recognition  and  intelligent  treatment,  Hippocrates  using  the 
ligature,  and  the  Roman  surgeons  the  knife,  as  is  done  to-day.  It  was 
observed,  however,  that  although  most  fistulas  recovered  promptly  after 
operation,  others  did  so  very  slowly  or  not  at  all,  and  that  a  ntimhor 
of  the  latter  patients  lost  in  health  and  often  died  of  consumption.  It 
was  therefore  assumed  that  all  fistula^  were  estal)lished  by  nature  for 
the  purpose  of  draining  injurious  "  humors  "  from  the  system,  and  if 
closure  were  attempted,  disaster  would  result.  Heurteloup  carried  this 
idea  to  such  an  extreme  that  he  actually  advised  the  production  of 
artificial  fistula}  in  consumptives. 

Among  the  general  pul)lic  these  erroneous  notions  are  still  prevalent. 
Physicians,  however,  now  universally  agree  that  most  fistuhie  should  he 
operated  on;  hut  when  tuberculosis  of  the  lungs  coexists,  opinions  are 
widely  divergent,  many  still  clinging  to  the  statement  of  Sir  Benjamin 
Brodie,  that  "  in  those  cases  in  which  a  fistula  in  ano  occurs  in  con- 
nection with  some  organic  disease  of  the  lungs  or  liver,  I  advise  you 
never  to  undertake  the  cure  of  the  fistula.  No  good  can  arise  from  an 
operation  under  these  circumstances;  but  if  you  perform  it,  one  of  two 
things  will  happen:  either  the  sinus,  although  laid  open,  will  never  heal 
as  usual,  or  the  visceral  disease  will  make  more  rapid  progress  after- 
wards, and  the  patient  will  die  sooner  than  he  would  have  done  if  he 
had  not  fallen  into  your  hands." 

In  looking  over  the  modern  text-books  it  is  seen  that  some  advise 
radical  intervention  in  all  cases  where  the  lungs  are  not  too  extensively 
involved,  while  others  are  more  or  less  conservative,  even  to  the  point 
of  condemning  all  operations  except  incisions  necessary  to  procuie 
drainage.  It  is  difficult  to  understand,  however,  why  the  lungs  should 
be  more  unfavorably  influenced  by  the  excision  of  a  local  focus  in  the 
vicinity  of  the  anus  than  l)y  the  removal  of  tuberculous  glands  of  the 
neck,  or  an  infected  joint,  kidney,  or  testicle;  and  for  this  reason,  as 
well  as  from  the  accumulation  of  much  clinical  evidence,  the  opinion 
has  gained  ground  that  tuberculous  fistulae  should  be  excised  thoroughly, 
and  that  there  is  just  as  much  reason  for  this,  and  just  as  little  danger, 
as  there  is  in  the  similar  treatment  of  surgical  tuberculosis  elsewhere. 

It  must  be  clearly  understood,  however,  that  great  care  should  be 
used  in  the  selection  of  cases.  Operations  should  not  be  done  in  the 
presence  of  advanced  pulmonary  trouble,  or  on  those  whose  resisting 
powers  are  manifestly  weak,  especially  if  the  local  lesion  is  an  extensive 
one;  nor  should  they  be  attempted  unless  there  is  a  fair  chance  for 
removal  of  all  diseased  tissue. 


TREATMENT  769 

If  an  operation  is  undertaken,  it  should  be  thorough.  Anything  short 
of  complete  excision  of  the  disease  is  often  worse  than  useless,  except  in 
those  comparatively  rare  instances  where  intervention  is  for  the  purpose 
of  securing  drainage  only.  Simply  slitting  up  the  sinus,  as  in  ordinary 
fistulge,  even  when  followed  by  curettement  or  the  use  of  the  thermo- 
cautery, may  be  sufficient  in  certain  cases,  especially  in  those  having  a 
strong  tendency  to  spontaneous  healing,  but  a  cure  cannot  be  relied  on. 
Mere  dilatation  of  a  sinus  is  useless,  as  is  also  the  employment  of  chem- 
icals, electrolysis,  and  the  ecraseur.  Even  the  use  of  the  elastic  ligature 
is  not  advisable,  in  spite  of  its  strong  recommendation  by  certain  authors. 

Although  tuberculous  fistulas  sometimes  are  made  to  heal  when  treated 
like  ordinary  fistula,  the  best  operation  is  complete  excision,  ^nth  im- 
mediate closure  of  the  wound.  In  the  majority  of  instances  primary 
union  will  occur,  Sternberg,  for  instance,  having  obtained  it  in  82  out 
of  105  cases;  but  if  inflammation  should  result,  part  or  all  the  wound 
can  be  reoperated.  and  treated  as  if  an  operation  for  an  ordinary  fistula 
had  been  done,  when  the  healing  will  be  satisfactory  if  the  disease  has 
been  removed  radically. 

If  possible,  operations  should  be  done  early,  before  extensive  involve- 
ment of  surrounding  tissues  takes  place,  the  most  favorable  time  being 
after  the  original  abscess  has  been  opened  and  as  soon  as  the  super- 
abundant inflammation  and  infiltration  have  subsided,  leaving  a  well- 
defined  fistulous  tract  which  can  be  extirpated  thoroughly  with  the  least 
sacrifice  of  tissue. 

The  most  favorable  cases  are  those  with  latent  pulmonary  lesions 
and  good  resisting  powers,  especially  when  the  fistula  is  surrounded  by 
considerable  fibrous  tissue.  If  rapid  ulceration  is  present,  with  lack  of 
induration,  the  outlook  is  correspondingly  bad.  Good  hygienic  sur- 
roundings and  a  favorable  climate  add  to  the  probability  of  recovery. 

The  reasons  for  an  unfortunate  result  are  several:  (1)  Operations, 
sometimes  prolonged  and  bloody,  are  done  on  patients  in  advanced 
stages  of  consumption  whose  progress  would  inevitably  be  downward, 
whether  operated  on  or  not,  and  to  whom  any  surgical  intervention 
must  be  harmful.  (2)  Fistulas  are  often  forerunners  of  exacerbations 
of  pulmonary  disease,  which  would  surely  follow  even  if  an  operation 
were  not  performed.  (3)  Incomplete  operations  are  frequently  done, 
followed  by  prompt  recurrence. 

The  method  of  operating  should  permit  of  thorough  exposure  and 
removal  of  everything  which  is  diseased.  An  excellent  procedure  is  to 
introduce  a  pair  of  bullet-forceps  through  the  well-dilated  anus,  grasp- 
ing the  mucous  membrane  above  the  fistulous  opening  in  the  bowel  and 
pulling  the  internal  end  of  the  fistula  well  out  of  the  anus.  Then,  by 
means  of  several  sharp  hooks  inserted  around  its  margin,  the  wound 
50 


770     TUBERCULOUS  ISCHIORECTAL  ABSCESS  AND  ANAL  FISTULA 

is  opened  out  to  the  fullest  extent  and  made  easily  accessible,  much  as  in 
plastic  operations  on  the  perineum,  and  with  knife  and  scissors  the  entire 
fistulous  tract  is  excised,  going  well  beyond  the  infected  portion.  Plastic 
operations,  or  even  skin-grafting,  may  be  necessary  to  cover  the  denuded 
area.  The  opening  should  be  closed,  if  possible,  with  silkworm-gut 
sutures,  which  enter  the  skin  on  one  side  of  the  wound,  pass  beneath 
it  within  the  tissues,  and  appear  on  the  other  side.  These  should  not 
be  tied  too  tightly.  The  bowels  should  be  locked  for  four  or  five  days 
and  the  sutures  removed  in  from  seven  to  ten  days.  Local  or  spinal 
anesthesia  may  be  employed  when  indicated. 


CHAPTER   VII 

TUBEECULOSIS    OF    THE    PERITONEUM 
By  L.  L.  McARTHUR 

Occurrence. — So  rarely  does  the  primary  invasion  of  the  peritoneum 
by  tuberculosis  occur  that  most  authorities  regard  it  as  secondary  to 
some  other  process  in  the  abdomen.  Citation  has  been  made,  because 
of  their  rarity,  of  cases  in  which  it  apparently  was  primary.  Many 
such  cases  on  further  analysis  have  shown  a  preceding  trauma,  with 
rupture  of  a  softened  mesenteric  (Heintze)  or  mediastinal  gland 
(Baumgarten),  with  immediate  infection  of  the  peritoneum  as  the  chief 
symptom  following  the  injury.  Bendorf's  case  of  a  mesocecal  tubercu- 
losis, with  general  peritoneal  tuberculosis  extending  therefrom,  without 
other  discoverable  lesion,  is  the  best  authenticated  case,  and  appears  to 
have  been  one  of  those  intestinal  invasions  without  lesion  of  the  mucosa. 
Statistically  (Bircher),  less  than  two  per  cent  of  all  cases  of  this  affec- 
tion have  been  regarded  as  primary. 

Attention  is  thus  earl}^  called  to  the  secondary  nature  of  the  peri- 
toneal tuberculosis,  because  both  its  diagnosis,  prognosis,  and  treatment 
will  in  part  be  influenced  by  the  determination,  when  possible,  of  the 
primary  focus.  Some  of  these  cases  being  removable  surgically,  a  cure 
of  both  the  primary  disease,  as  well  as  the  secondary  complication,  may 
be  affected  by  operation.  The  lymphogenous  mode  of  infection  being 
the  chief  one,  mention  only  need  be  made  of  the  ileocecal  tuberculosis, 
tuberculosis  of  female  genitalia,  tuberculosis  of  the  vas  deferens,  and 
mesenteric  gland  tuberculosis  to  appreciate  the  varying  atria  of  in- 
fection. 

Classification. — Considerable  difficulty  exists  in  classifying  the  vary- 
ing manifestations  of  this  disease  of  the  peritoneum,  since  neither  on 
pathologic  nor  clinical  basis  can  it  be  sharply  separated  into  distinct 
varieties.  The  safest  course  is  to  regard  it  as  a  widely  varying  mani- 
festation of  a  single  process  whose  severity,  extent,  and  character  are 
dependent  on  many  factors. 

On  a  pathologic  basis  it  may  be  divided  into  two  general  groupings: 
(1)  Simple  tuberculosis  of  the  peritoneum;  (2)  tuberculous  peritonitis. 

771 


772  TUBERCULOSIS  OF  THE   PERITONEUM 

In  the  former  vre  find  the  peritoneum  studded  with  small  gray  miliary 
nodules,  unaccompanied  by  practically  any  clinical  symptoms.  The  mil- 
iary bodies  may  be  localized  or  general,  numerous  or  discrete.  This 
variety,  seen  and  described  almost  solely  by  the  pathologist,  has  but 
little  clinical  interest.  If  there  is  an  exudate,  it  may  escape  detection 
until  the  pelvis  overflows  (1,500  c.c,  this  being  about  the  quantity 
which  may  escape  casual  observation). 

Tuberculous  peritonitis  is  often  seen  by  the  surgeon.  It  produces 
many  clinical  symptoms  requiring  surgical  intervention.  As  a  direct 
outgrowth  of  this  systematic  surgical  interference  there  has  been  evolved 
a  necessary  subclassification  based  on  the  clinical  findings,  viz.:  (a)  The 
adhesive  tuberculous  peritonitis;  (h)  the  ascitic  tuberculous  peritonitis; 
(c)  the  cheesy  tuberculous  peritonitis. 

Since  the  observation  of  a  cure  by  laparotomy,  made  by  Spencer 
Wells,  the  ascitic  form  has  been  the  one  of  most  interest  lioth  to  the 
internist  and  the  surgeon,  for  with  this  type  they  have  had  their  greatest 
encouragement  based  on  results.  With  these  surgical  experiences,  too, 
has  come  the  knowledge  that  while  in  the  ascitic  variety  most  cures  were 
to  be  obtained,  other  varieties  exist  not  always  to  be  recognized  prior  to 
operation.  This  necessitated  the  addition  of  (at  least)  the  other  two 
classifications  above  given. 

The  ascitic  form,  as  its  name  implies,  is  associated  with  a  fluid 
exudate,  of  varying  quantity  and  quality,  of  large  or  small  albumin 
content,  clear  or  cloudy,  colorless  or  straw-colored,  with  or  without 
fibrinous  flakes,  even  bloody  or  purulent.  The  fluid,  usually  frse  in  the 
general  cavity,  is  sometimes  found  encysted,  when  the  differential  diag- 
nosis may  be  rendered  very  difficult.  The  peritoneum,  thus  bathed,  and 
held  apart  by  fluid,  is,  as  a  rule,  free  from  adhesions,  while  presenting 
the  characteristics  attending  the  invasion  1)y  tubercle  of  serous  mem- 
branes elsewhere.  The  degree  of  infectivity  of  the  fluid  also  varies 
extremely,  sometimes  requiring  most  careful  animal  inoculations  to 
demonstrate  its  tuberculous  character. 

An  experimental  basis  (Levi-Sirugue)  has  been  brought  forward 
explaining  the  variations  as  dependent  on  the  degree  of  virulence  of 
the  organisms  introduced.  Thus  the  cheesy — richest  in  bacilli — is  the 
most  severe,  while  the  ascitic  or  the  dry  forms  contained  few  bacilli, 
and  these  were  of  reduced  virulence. 

Symptomatology. — The  ascites  rounds  out  the  belly  often  to  marked 
prominence ;  although  generally  free,  the  fluid  may  be  encysted  and  uni- 
lateral. The  navel  may  protrude  in  a  somewhat  significant  manner,  its 
veins,  through  an  inflammatory  process,  making  an  omphalitis,  to  which 
B.  Yeo  has  called  attention.  Later,  intestinal  fistula  may  develop  at 
this  site  and  the  ascitic  fluid  may  escape.     Occasionally  the  ascitic  fluid 


SYMPTOMATOLOGY  773 

escapes  into  an  intestinal  perforation.  This  Czerny  has  named  the 
death  sign. 

The  fever  is  of  the  same  irregular  character  seen  in  other  similar 
processes.  Pain  is  positive,  and  present  in  eighty  per  cent;  is  sometimes 
general,  at  other  times  localized — e.g.,  in  the  vaginal  vault  (Murphy) 
or  in  the  intestines.  Vomiting  is  not  infrequent.  The  interference 
in  motility  caused  by  the  peritoneal  involvement  leads  to  constipation, 
cramps,  and  diarrhea.  The  latter  is  perhaps  due  to  the  putrefactive 
changes  likely  to  occur  in  stagnating  intestinal  contents.  Similarly, 
involvement  of  the  vesical  peritoneum  gives  vesical  pain  without  urinary 
pathologic  findings.  Sweating  may  be  a  symptom.  Mesenteric  and 
inguinal  glands  may  become  involved. 

In  the  third  form,  accompanied  as  it  is  by  little  fluid  exudate,  the 
tuberculous  masses  can  usually  be  palpated,  irregular  in  position,  out- 
line, and  number ;  the  omentum  often  becomes  caked,  can  be  palpated, 
is  usually  somewhat  mobile,  and  emitting  a  peritoneal  friction  on  aus- 
cultation. No  age  is  exempt,  from  the  newborn  babe  to  the  aged,  but 
the  greatest  frequency  is  between  twenty  and  forty. 

A  remarkable  discrepancy  has  been  noted  between  the  relative  fre- 
quency in  the  male  and  female,  when  the  clinical  are  compared  with 
the  dead-house  data,  surgeons  generally  agreeing  that  the  disease  is 
observed  three  times  as  frequently  in  the  female  as  in  the  male,  while 
the  pathologists  reverse  these  figures.  It  is  probable  that  the  origin  in 
or  the  early  involvement  of  the  female  genitalia  produces  conditions 
more  amenable  to  surgery  than  in  the  male,  and  hence  more  females 
come  to  operation. 

The  Adhesive  Form. — On  the  other  hand,  the  adhesive  form  may 
result  in  an  almost  total  obliteration  of  the  peritoneal  cavity,  cementing 
the  abdominal  organs  into  a  single  mass,  so  that  the  greatest  difficulty 
is  experienced  by  the  surgeon  in  orientation.  The  mass  made  by  these 
adhesive  invasions  sometimes  deceives  so  thoroughly  that  operative  in- 
terference for  suspected  tumor  only  then  reveals  its  true  nature.  If 
effort  Ije  made  to  separate  the  same,  even  with  the  greatest  care,  fistulfe 
may  result  because  of  the  extreme  friability  of  a  tuberculous  intestinal 
wall. 

The  third  form,  of  cheesy  tuberculous  peritonitis,  possibly  only  a 
terminal  stage  of  the  previous  form,  is  characterized  by  those  degen- 
erative changes  which  mark  the  terminal  stage  of  tuberculosis  anywhere 
— i.  e.,  soft,  gray,  cheesy  tubercles,  covering  both  parieties  and  peritoneal 
surfaces  of  the  abdominal  organs.  Both  the  adhesive  and  the  cheesy 
types  have  proved  themselves  decidedly  less  amenable  to  surgical  inter- 
ferences than  have  the  ascitic,  since  fistulas,  abscesses,  and  other  com- 
plications are  frequent  sequences  of  even  a  simple  exploration. 


774  TUBERCULOSIS  OF  THE   PERITONEUM 

All  three  varieties  are  but  stages  of  one  and  the  same  process.  All 
three  may  exist  in  the  same  case;  as  early  as  1869  the  elder  Klebs 
suggested  a  similar  classification. 

For  years  it  has  been  kno\ATi  that  there  could  be  produced  experi- 
mentally a  condition  of  the  peritoneum  so  closely  resembling  peritoneal 
tuberculosis  that  clinically,  by  autopsy  or  microscopic  examination,  it 
could  not  be  differentiated.  Bacteriologic  and  inoculation  experiments 
alone  could  determine  the  noninfectious  nature  of  these  pseudotubercles. 
Clinically,  this  condition  has  been  observed  as  induced  by  a  ruptured 
echinococcus  cyst,  by  distomum,  by  echinococcus  booklets,  and  by  choles- 
terin  crystals.  To  it  has  been  given  the  name  foreign-body  tuberculosis. 
It  is  of  such  rarity  that  it  deserves  but  passing  mention,  though  its 
recognition  might  spare  the  patient  much  mental  as  well  as  physical 
suffering. 

Diagnosis. — In  an  ailment  appearing  in  so  many  forms,  having  its 
origin  in  so  many  different  foci,  mimicking  almost  every  abdominal 
disease,  it  is  not  strange  that  until  recent  years  its  differentiation  was 
difficult  or  impossible.  With  the  newer  methods  of  the  laboratory  added 
to  our  established  methods  it  has  now  become  possible  to  determine  at 
least  the  presence  or  absence  of  a  tuberculous  process  with  reasonable 
accuracy.     Something  might  here  be  said  in  this  regard. 

(1)  TuhercuUn  (Koch,  Wright,  v.  Pirquet,  Calmette).  (2)  In- 
oculation.— When  Koch  first  presented  his  discovery  of  the  remarkable 
influences  of  tuberculin,  use  was  made  of  it  both  as  a  diagnostic  and 
therapeutic  measure.  Unfortunately,  the  results  were  often  disappoint- 
ing, dangerous,  or  doubtful.  Later  workers,  like  Wright,  have  shown 
that  much  can  be  determined  by  a  study  of  the  blood  in  relation  to  the 
capacity  of  its  leucocytes  to  ingest  tubercle  bacilli  (opsonic  index),  and 
through  tuberculin  in  minute  doses  to  improve  this  capacity.  Eighty- 
six  per  cent  of  cases  can  tlius  be  determined. 

y.  Pirquet  has  likewise  devised  an  ingenious  and  safe  method  of 
utilizing  tuberculin  as  a  diagnostic  measure,  the  accuracy  of  which  is 
peculiarly  great  in  children,  and  sufficiently  so  in  adults  to  be  a  con- 
firmatory aid.     Its  application  has  been  elsewhere  described. 

Calmette's  method,  known  as  the  opbthalmo-reaction,  is  dependent 
on  the  conjunctivitis  provoked  in  the  eye  of  the  tuberculous,  when  a 
drop  of  a  one-per-cent  solution  of  tuberculin  is  instilled.  So  active  is  this 
reaction  in  the  tuberculous  that  it  is  advisable  to  dilute  to  a  greater 
degree  than  one  per  cent,  and  to  advise  the  patient  of  possible  discomfort. 

A  series  of  tests  was  made  in  my  laboratory  by  Dr.  Mary  Lincoln, 
to  determine  the  relative  values  of  the  cutaneous  tuberculin  test  (v. 
Pirquet),  the  conjunctival  tuberculin  test,  and  the  tuberculo-opsonic 
index  in  the  diagnosis  of  tuberculosis. 


TREATMENT 


775 


The  following  table  gives  the  results  of  these  tests  on  three  classes 
of  cases: 


Cutaneous  Te.st 

Conjunctival  Test 

Tubebculo-Opsonic 
Index  (I.) 

Classes  of  Cases 

Num- 
ber of 
Cases 

Positive 

Num- 
ber of 
Cases 

Positive 

Num- 
ber of 
Cases 

One  or 
more  I 

Above  or 
Below 

Normal  I 

Two  or 
more  I 

Above  or 
Below 

Normal  I 

Pulmonary     Tuber- 
culosis, Stage  III . 

Bone  and  Joint  Tu- 
berculosis   

Nontuberculous 
Clinically 

79 
47 
32 

46% 

80% 

1% 

87 
54 
34 

36% 

88% 

0.03% 

74 
60 
34 

70% 
61% 
40% 

34% 
37% 
10% 

Inoculation  methods  as  now  practiced  in  pathologic  laboratories 
enable  us  (when  possible  to  secure  some  of  the  suspected  exudate) 
to  determine  the  infectivity  of  an  exudate  much  earlier  and  more 
surely. 

Treatment. — How  changed  is  the  opinion  as  to  the  curability  of 
tuberculosis  of  the  peritoneum  can  be  appreciated  by  those  long  in 
practice.  From  being  considered  an  incurable  condition,  either  by 
physician  or  surgeon,  it  has  been  turned  over  to  surgery  because  of 
demonstrated  cures  in  a  very  large  percentage  of  cases  (sixty  to  seventy 
per  cent).  Reclaimed  by  the  internists  as  possible  of  cure  without 
operation,  the  position  now  is  that  a  selection  of  cases  should  be  made, 
some  being  distinctly  amenable  to  one,  some  to  the  other  form  of  treat- 
ment. Since  pathologists  have  proved  ninety  per  cent  of  these  cases  have 
other  lesions,  attention  must  be  directed  to  the  entire  disease,  and  not 
solely  to  the  peritoneal  manifestation.  Therefore,  all  of  the  modern 
means  of  combating  this  disease  should  be  em])loyed.  By  this  is  meant 
more  the  hygienic,  climatic,  and  atmospheric  influences,  the  actinic  rays 
of  the  sun  and  the  Roentgen  ray,  ratiier  than  medicaments.  Though 
many  of  these,  too,  may  prove  aids  to  convalescence,  less  dependence 
should  be  placed  on  them  than  in  the  past. 

In  an  average  case,  there  being  no  condition  requiring  early  surgical 
interference,  the  internist  should  be  given  an  opportunity  to  apply  the 
])est-known  methods.  If  after  the  lapse  of  six  to  eight  weeks  distinct 
improvement  is  not  demonstrable,  the  case  should  then  be  transferred 
to  the  surgeon.  Although  it  is  impossil)le  definitely  to  state  which 
patients  should  be  operated  and  which  should  not,  we  can  say  that 
operation  is  indicated  in  (1)  the  distinctly  ascitic  cases;  (2)  cases 
with  a  remediable  local  lesion — e.  g.,  tuberculous  appendix,  tuberculous 


776  TUBERCULOSIS  OF  THE   PERITONEUM 

cecum,  tuberculous  genitalia,  etc. ;  ( 3 )  cases  that  have  failed  to  improve 
under  the  accepted  modern  methods. 

Condensing  the  results  of  the  innumerable  operative  procedures  which 
have  been  evolved  from  the  theories,  practices,  and  experiments,  one 
can  say  that  simple  median  incision,  with  irrigation,  gives  the  best 
results.  This  implies  the  escape  of  the  ascitic  fluid,  flushing  with  a 
sterile  normal  salt  solution,  emptying  the  same,  and  hermetic  closure 
of  the  abdomen.  All  the  variations  of  this  procedure  have  been  care- 
fully anal.yzed  (Bircher),  with  the  conclusion  that  this  simple  procedure 
described  gives  the  best  results.  When  the  type  of  the  case  varies  from 
the  usual,  then  some  special  procedure  may  l^ecome  necessary,  in  which 
event  much  must  depend  on  the  surgical  judgment  of  the  operator. 


CHAPTER  VIII 
TUBERCULOSIS    OF    THE    GENITO-URINARY    SYSTEM 
By  LEONARD  FREEMAN 


GENERAL    CONSIDERATIONS 

Numerous  observations  seem  to  prove  that  tuberculosis  may  occa- 
sionally have  its  jjrimary  seat  in  the  genito-urinary  system,  in  the 
kidneys,  testicles,  seminal  vesicles,  prostate,  or  bladder.  In  the  vast 
majority  of  cases,  however,  it  is  secondary  to  some  other  focus,  usu- 
ally in  the  lungs,  which  may  be 
small  or  latent,  thus  easily  escaping 
attention. 

Theoretically,  infection  may  take 
place  in  several  ways — (1)  tlirough 
the  blood,  (2)  tlirough  the  lymphat- 
ics, (3)  by  contiguity,  or  (4)  through 
the  urethra,  uterus,  or  Fallopian  tubes 
— but  there  is  good  reason  to  believe 
that  it  seldom  occurs  except  through 
the  circulation.  At  various  times  at- 
tention has  been  called  to  the  urethra 
and  uterus  as  possible  channels  of 
entrance  for  the  tubercle  bacillus,  al- 
though little  or  nothing  has  been 
demonstrated  in  this  regard. 

In  considering  the  origin  and 
progress  of  infection  in  the  male,  the 
bladder  may  be  regarded  as  a  central 
])oint  surrounded  by  the  kidneys,  tes- 
ticles, seminal  vesicles,  and  ])rostate; 
the  generative  organs,  including  the 
prostate,  forming  one  group,  and  the 

urinary  organs  another  (Fig.  181).  In  the  female  the  conditions  are 
similar,  the  uterus,  tubes,  and  ovaries  taking  the  place  of  the  prostate, 
seminal  vesicles,  and  testicles. 

51  777 


Fig.  181.  —  Indicating  how  the 
Urinary  Group  of  Organs 
(Kidneys,  Ureters,  and  Blad- 
der) IS  Pathologically  Dis- 
tinct FROM  the  Generative 
Group  (Testicles,  Vasa  Def- 
ERENTiA,  Seminal  Vesicles, 
and  Prostate),  with  the  Blad- 
der AS  A  Central  Point. 


778  TUBERCULOSIS   OF  THE   GENITO-URINARY   SYSTEM 

It  was  formerly  taught  that  tuberculosis  nearly  always  began  in  the 
bladder  or  prostate,  and  from  there  extended  up  the  ureters  to  the  kid- 
neys, or  down  the  vasa  deferentia  to  the  testicles  (Guy on)  ;  but  recently 
these  views  have  been  questioned  by  Baumgarten,  Kiimmel,  von  Bruns, 
and  others,  who  maintain  that  exactly  the  reverse  is  true.  By  means  of 
numerous  experiments  on  rabbits,  conducted  during  the  course  of  sev- 
eral years,  Baumgarten  and  Kramer,  corroborated  by  Giani,  have  dem- 
onstrated that,  although  extensive  tuberculosis  of  the  bladder  often 
followed  the  injection  of  tubercle  bacilli  through  the  urethra,  in  no  in- 
stance and  under  no  circumstances  did  the  disease  ascend  to  the  kidneys 
or  descend  to  the  testicles,  even  after  as  long  a  time  as  a  year  and  a  half; 
while,  on  the  other  hand,  when  tuberculosis  of  the  kidneys  or  testicles 
was  first  produced,  it  readily  infected  the  bladder.  In  other  words,  the 
tubercle  bacillus  follows  the  course  of  the  secretions  and  excretions  in 
the  genito-urinary  system,  up  the  vas  deferens  and  down  the  ureters.  It 
may  also  be  said,  with  much  probability,  that  in  case  the  invasion  takes 
place  through  the  lymphatics  of  the  ureters  and  vasa  deferentia,  its 
progress  will  be  similar,  owing  to  the  distribution  of  the  lymph  vessels. 
As  reasons  for  this  tendency  of  the  tubercle  bacillus  to  float  with  the 
current  only  may  be  mentioned  its  lack  of  voluntary  motion  and  its  in- 
ability to  multiply  in  the  excretions  and  secretions  of  the  body,  as  do 
man}''  other  microorganisms. 

Hence,  it  is  maintained,  from  experimental  and  clinical  findings,  that 
primary  infection  of  the  bladder  occurs  rarely,  if  at  all;  but  tuberculosis 
has  its  origin,  in  the  great  majority  of  instances,  in  the  kidneys,  and 
occasionally  in  the  testicles.  Early  nephritic  involvement,  however,  is 
often  difficult  to  detect  without  skilled  cystoscopic  investigation,  owing 
to  its  painless,  insidious  character,  thus  causing  the  attention  of  both 
physician  and  patient  to  become  concentrated  on  the  secondary  lesion  of 
the  bladder. 

A  strong  clinical  point  in  favor  of  the  above  views  is  the  fact,  sup- 
ported by  innumerable  observations,  that  tuberculosis  of  the  bladder  has 
a  marked  tendency  toward  recovery  when  a  diseased  kidney  or  testicle  is 
removed. 

TUBERCULOSIS    OF    THE    TESTICLES 

This  is  nearly  always  secondary  to  tuberculosis  elsewhere,  although 
many  observations  seem  to  show  that  it  may  occasionally  be  primary.  It 
has  even  been  maintained  that  the  germs  can  exist  in  the  testicles  at 
birth,  but  this  is,  perhaps,  doubtful.  It  is  true,  however,  that  infection 
sometimes  appears  in  those  who  are  otherwise  in  perfect  health  and  from 
whom  no  tuberculous  history  can  be  obtained,  either  as  regards  them- 
selves or  their  family. 


TUBERCULOSIS  OF   THE  TESTICLES  779 

Tuberculosis  of  the  testicle  occurs  ver}-  frequently  during  the  age  of 
greatest  sexual  activity,  although  it  may  appear  in  later  life  or  even  in 
old  age.  It  is  seen  in  children,  and  has  occasionally  been  reported  in 
infants.  Those  cases  which  exist  as  part  of  a  general  miliary  tubercu- 
losis will  not  be  considered  here. 

As  exciting  causes  of  more  or  less  moment  may  be  mentioned  injury 
of  the  testicle  and  gonorrheal  epididymitis;  but,  as  both  occur  with  such 
frequency,  it  is  diflficult  to  determine  their  true  weight  as  etiologic 
factors;  although  it  must  be  admitted  that  the  experiments  are  quite 
convincing  in  which  tuberculosis  of  the  testicle  has  appeared  following 
crushing  of  the  organ  in  infected  animals. 

Pathology. — The  tuberculous  process  almost  invariably  appears  first 
in  the  epididymis,  rather  than  in  the  body  of  the  testicle  or  in  the  vas 
deferens,  although  the  latter  structure  often  becomes  secondarily  in- 
fected. Occasionally,  however,  the  body  of  the  testis  may  be  the  seat  of 
the  primary  lesion.  The  belief  is  steadily  gaining  ground,  and  is  now 
quite  generally  accepted,  that  the  tubercle  bacillus  reaches  the  epididymis 
through  the  blood,  the  anatomic  arrangement  of  the  vessels  being  favor- 
able to  its  lodgment  and  growth.  This  view,  strongly  supported  by  ex- 
periments on  aninuils  and  l)y  clinical  observation,  is  diametrically  op- 
posed to  the  teaching  of  Guyon,  which  was  formerly  universally  accepted, 
in  which  infection  was  supposed  to  descend  along  the  vas  deferens  from 
the  bladder,  prostate,  or  seminal  vesicles.  The  question  is  of  much 
importance  in  its  bearing  on  treatment. 

The  lesions  manifest  themselves  in  the  epididymis  as  a  local  dis- 
seminated tuberculosis,  or,  which  is  more  frequently  the  case,  as  nodules 
of  considerable  size  made  up  of  conglomerations  of  small  tubercles. 
Caseation  and  liquefaction  are  apt  to  occur  as  in  tuberculosis  elsewhere 
(Plate  III,  Fig.  2).  The  disease  may  secondarily  invade  the  scrotum  or 
the  body  of  the  testis,  usually  producing,  in  the  latter  situation,  sufficiently 
large  disseminated  tubercles  to  be  easily  discernible  on  section  of  the  organ. 
The  process  generally  spreads  up  the  vas  deferens,  manifesting  itself 
either  as  more  or  less  uniform  thickening,  or  as  isolated  nodules,  which 
can  be  detected  by  palpation.  In  advanced  cases  the  whole  testicle  may 
be  converted  into  a  large  indurated  mass,  to  which  the  infiltrated  and 
livid  skin  is  closely  adherent,  and  throughout  which  exist  caseous  masses 
and  liquefied  tuberculous  foci  in  a  matrix  of  fibrous  tissue.  Chronic 
fistulse  frequently  form,  which  discharge  pus  and  caseous  material.  It 
is  not  probable  that  living  tubercle  bacilli  often  find  their  way  into  the 
seminal  fluid,  or  that  infection  of  the  ovum  from  this  source  is  greatly 
to  be  feared  (Orth). 

Symptoms. — As  in  many  other  tul)erculous  lesions,  the  disease  usually 
develops  so  slowly  and  painlessly  tliat  it  may  reach  quite  an  advanced 


780  TUBERCULOSIS  OF   THE   GENITO-URINARY   SYSTEM 

stage  before  it  is  accidentally  discovered  as  a  hard  nodule  in  the  epi- 
didymis. It  may  be,  then,  that  some  injury  to  the  organ  leads  to  the 
detection  of  the  trouble,  and  is  erroneously  assigned  as  the  cause.  Fur- 
ther progress,  which  may  be  rapid,  but  usually  extends  over  many  weeks, 
months,  or  even  years,  is  characterized  by  increase  in  the  circumference 
of  the  nodule,  accompanied  often  by  the  formation  of  a  hydrocele  of 
moderate  size.  The  skin  of  the  scrotum  becomes  adherent,  brawny,  and 
of  a  dark-red  or  livid  color,  followed  by  the  perforation  of  a  tuberculous 
abscess.  Persistent  and  annoying  fistulae  are  thus  formed,  through  which 
secondary  infection  takes  place,  and  which  discharge  pus  and  caseous 
debris,  and  through  which  may  protrude  masses  of  unhealthy  granula- 
tions ("fungus  of  the  testicle"). 

Involvement  of  the  vas  deferens  takes  place  sooner  or  later,  although 
it  may  be  long  delayed.  It  can  easily  be  felt  as  a  uniform  thickening  or 
as  separate  nodules  (Plate  III,  Fig.  2),  and  is  generally  more  pronounced 
in  tlie  lower  portion,  although  this  is  not  always  the  case. 

The  disease  also  manifests  itself  in  an  acute  form ;  either  primary,  or 
secondary,  to  an  already  existing  nodule.  In  such  cases  the  epididymis 
is  rapidly  invaded  by  disseminated  tubercles,  which  cause  swelling,  ac- 
companied by  pain  and  fever.  In  fact  the  process  may  be  so  acute  as  to 
closely  reseml)le  an  attack  of  gonorrheal  epididymitis,  with  which  it  is 
easily  confused. 

In  ordinary  chronic  tuberculosis  of  the  testicle,  general  symptoms 
are  trivial  or  absent,  unless  mixed  infection  supervenes;  but  in  the  acute 
form  a  considerable  rise  in  temperature  and  acceleration  of  the  pulse 
may  occur,  accompanied  by  severe  pain.  A  certain  amount  of  mental 
depression  may  exist,  such  as  is  found  with  other  affections  of  the  genital 
organs.    Tlie  sexual  capacity  is  seldom  affected. 

Although  tuberculosis  almost  always  liegins  in  but  one  testicle,  the 
opposite  organ  frequently  becomes  infected  sooner  or  later.  According 
to  Kocher,  this  occurs  in  at  least  seventy-five  per  cent  of  the  cases,  while 
von  Bruns  ])laces  the  number  at  fifty  per  cent,  the  disease  being  already 
bilateral  in  about  one  fourth  of  the  patients  operated  on.  If  involve- 
ment of  the  other  testicle  follows  unilateral  castration,  it  almost  always 
does  so  within  three  years. 

Diagnosis. — Tuberculosis  is  easily  differentiated  from  most  tumors, 
because  it  occupies  the  epididymis  and  not  the  body  of  the  testis,  al- 
lliough  a  tense  hydrocele  may  cause  some  confusion;  but  between  tuber- 
culosis and  the  indurations  remaining  after  gonorrheal  inflammation 
the  diagnosis  is,  at  times,  extremely  difficult,  especially  as  tuberculosis 
seems  frequently  to  follow  gonorrhea.  The  presence  of  tuberculosis  in 
the  lungs,  kidneys,  or  bladder,  and  particularly  the  existence  of  nodules 
in  the  prostate,  seminal  vesicles,  and  vas  deferens,  is  of  much  assistance 


TUBERCULOSIS  OF   THE   TESTICLES  781 

in  arriving  at  a  correct  conclusion.  Involvement  of  the  skin,  with  or 
without  chronic  sinuses,  is  almost  pathognomonic.  Fibroid  tumors  of 
the  epididymis  are  usually  known  by  their  smoothness,  their  regularity 
of  outline,  and  the  absence  of  a  tendency  to  increase  much  in  size.  Cysts 
are  elastic  and  smooth,  and  if  large  they  are  translucent. 

T\'hen  syphilis  affects  the  body  of  the  testis  it  is  not  difficult  to  distin- 
guish it  from  tuberculosis,  which  begins  in  the  epidid}Tiiis;  but  when 
gummatous  lesions  exist  in  the  latter  structure,  the  differentiation  is  not 
so  easy.  A  diagnosis  can  usually  be  made,  however,  by  noting  the  his- 
tory of  syphilis,  the  lack  of  bladder  symptoms  and  the  absence  of  nodules 
in  the  prostate,  seminal  vesicles,  and  vasa  deferentia,  as  well  as  the  ab- 
sence of  sinuses  and  of  adhesions  of  the  scrotal  integument.  In  case  of 
doubt,  a  course  of  syphilitic  treatment  should  always  be  employed  before 
operation  is  considered. 

Treatment. — It  is  undoubtedly  true  that  tuberculosis  of  the  testicle 
may  recover  spontaneously,  or  at  least  become  indefinitely  latent,  espe- 
cially in  a  favorable  climate  and  under  good  hygienic  conditions ;  but  this 
cannot  be  depended  on,  and  it  should  not  be  lost  sight  of  that,  while 
awaiting  such  recovery,  the  disease  may  spread  along  the  vas  deferens  to 
the  seminal  vesicle,  the  prostate,  and  even  the  bladder,  thus  getting  be- 
yond surgical  control  and  doing  more  or  less  irreparable  damage.  Hence, 
as  a  rule,  the  most  reasonable  procedure  is  to  remove  the  testicular  focus 
as  early  as  possible.  Even  if  the  disease  is  supposed  to  progress  from 
above  downward,  instead  of  from  below  upward,  it  must  be  admitted, 
from  the  statistics  of  von  Bruns,  Simon,  and  others,  that  the  higher 
lesions,  even  when  far  advanced,  are  favorably  influenced  and  often  cured 
by  the  removal  of  the  testicle. 

If  it  is  decided  to  use  expectant  treatment,  as  is  invariably  done  by 
some  surgeons  in  incipient  cases,  and  in  those  in  which  the  involvement 
is  not  great,  the  best  hygienic  surroundings  should  be  secured,  including 
a  favorable  climate,  if  possible.  Local  applications  are  of  little  or  no 
service,  the  whole  question  hinging  rather  on  the  resisting  powers  of  the 
patient,  which  should  be  increased  in  every  available  way.  In  this  con- 
nection the  vaccine  therapy  of  Wright  is  attracting  much  attention,  and 
undoubtedly  deserves  consideration,  although  its  reliability  has  not  yet 
been  sufficiently  demonstrated.  It  should  be  used  as  an  adjunct  to 
surgery  rather  than  as  a  substitute  for  it,  and  may  be  employed  in  mild 
or  incipient  cases,  or  in  those  which  are  no  longer  active,  whether  sinuses 
exist  or  not.  But  where  there  is  much  diseased  tissue,  or  the  process  is 
an  active  one,  surgery  should  have  the  preference.  As  a  precaution 
against  relapses,  it  is  always  in  place  following  operative  measures. 

Bier's  treatment  should  also  be  mentioned,  in  which  constriction  of 
the  upper  part  of  the  scrotum  is  made  by  means  of  a  rubber  band  applied 


782  TUBERCULOSIS  OF  THE  GENITO-URINARY  SYSTEM 

so  as  to  secure  a  moderate  degree  of  venous  hyperemia  of  the  testicle;  or 
a  similar  result  may  be  obtained  by  the  employment  of  a  dr}^  cup,  this 
being  especially  useful  where  a  sinus  exists.  In  this  location,  however, 
the  reliability  of  Bier's  methods  is  not  so  well  established  as  in  parts 
where  they  can  be  applied  more  accurately. 

The  injection  of  various  medicaments,  such  as  chlorid  of  zinc  or  an 
emulsion  of  iodoform,  directly  into  the  epididymis,  cannot  be  recom- 
mended, owing  to  the  great  pain  which  accompanies  the  procedure  and 
the  rarity  of  favorable  results. 

At  the  present  time  operative  treatment  undoubtedly  offers  the  best 
prospect  of  permanent  cure,  and  should  be  considered  in  every  case  unless 
decided  contraindications  exist,  such  as  extensive  and  hopeless  tubercu- 
losis elsewhere.  By  this  is  meant  a  radical  operation,  although  palli- 
ative procedures  are  occasionally  advisable  where  radical  measures  are 
contraindicated,  OAving  to  the  general  condition  or  prejudices  of  the 
patient. 

Palliative  Operations. — These  usually  consist  in  the  curettement 
and  cauterization  of  sinuses,  and  the  injection  into  them  of  various  anti- 
septics. A  curettement  should  be  thorough,  with  the  object  of  removing 
all  caseous  and  infected  material,  although  it  is  seldom  possible  to  ac- 
complish this  with  satisfaction.  If  cauterization  is  resorted  to,  it  should 
be  repeated  frequently,  employing  either  the  electrocautery,  chlorid  of 
zinc,  or  ninety-five  per  cent  carbolic  acid.  For  purposes  of  antiseptic 
irrigation,  tincture  of  iodin,  of  considerable  strength,  is  of  service.  Ee- 
section  between  ligatures  of  a  portion  of  the  spermatic  cord,  as  advocated 
by  Mauclaire,  is  no  longer  practiced. 

Eadical  Operations. — These  are  of  two  kinds — (1)  resection  of  the 
epididymis,  and  (2)  castration. 

Epidiclymectoiny  deserves  consideration  in  every  case,  especially  when 
both  testicles  are  diseased.  The  loss  of  both  organs  is  not  without  occa- 
sional psychic  effect,  and  the  "  internal  secretions  "  are  of  importance. 
The  sexual  desires  and  capacities  also  suffer  after  double  castration;  oc- 
casionally, however,  to  a  surprisingly  small  extent.  The  fact  that  many 
patients  will  readily  consent  to  resection  of  the  epididymis,  while  reject- 
ing castration  with  horror,  necessarily  has  much  weight  in  the  choice  of 
an  operation. 

The  removal  of  the  epididymis  has  its  justification  in  the  fact  that 
tuberculous  processes  almost  alwaj^s  begin  in  that  portion  of  the  testicle, 
involving  the  body  of  the  organ  later,  if  at  all.  This  is  well  shown  in  Plate 
III,  Fig.  3.  Hence  there  must  be  a  time  when  epididymectomy  is  just  as 
effective  as  castration,  and  it  should  be  the  operation  of  choice  in  cases 
which  are  seen  early  and  in  those  which  have  not  progressed  too  far. 
Yon  Bruns,  who  strongly  favors  castration,  asserts  that  the  body  of  the 


TUBERCULOSIS  OF  THE  TESTICLES  783 

testis  is  involved  in  about  18  per  cent  of  the  cases  at  the  end  of  two 
months,  24  per  cent  after  three  months,  40  per  cent  after  six  months, 
and  60  per  cent  or  more  in  later  cases.  Even  if  this  is  considered  to  be 
an  extreme  statement,  it  emphasizes  the  fact  that,  if  epididymectomy  is 
resorted  to,  it  should  be  done  as  early  as  possil)le.  As  it  is  often  impos- 
sible to  determine  the  exact  condition  from  external  inspection,  every 
operation  should  be  at  first  exploratory  in  its  nature.  It  may  even  be 
necessary  to  cut  into  the  body  of  the  testis,  as  one  would  slit  open  a 
kidney  at  an  autopsy,  before  a  decision  can  be  reached  between  epi- 
did3'mectomy  and  castration. 

In  operating,  the  epididymis  should  be  resected  as  a  whole,  even 
though  but  a  portion  is  diseased,  carefully  respecting  the  vascular  attach- 
ments of  the  cord  to  the  body  of  the  testis.  If  involvement  of  the  tunica 
albuginea  exists,  castration  should  be  strongly  considered.  As  a  rule  the 
vas  should  be  isolated  up  to  the  internal  ring,  and  divided  as  high  as 
possible,  as  in  castration  (Plate  III,  Fig.  3).  It  has  been  claimed  that 
if  the  vas  is  implanted  into  the  remains  of  the  epididymis,  or  into  the 
body  of  the  testicle,  through  an  incision  in  the  tunic,  its  permeability  to 
spermatozoids  may  be  restored.  This  can  be  tried  in  appropriate  cases, 
when  the  vas  appears  to  be  free  from  disease,  but  the  outcome  is,  to 
say  the  least,  questionable,  and  the  chance  of  cure  lessened. 

When  the  body  of  the  testis  is  left,  a  certain  amount  of  atrophy  usu- 
ally takes  place ;  but  in  many  instances  it  is  but  slight — an  argument  in 
favor  of  the  persistence  of  the  function  of  "  internal  secretion."  If  the 
tuberculous  process  recurs,  castration  can  then  be  done,  and  in  the  mean- 
time there  is  but  little  risk  of  extension  of  the  disease  because  of  the 
absence  of  the  vas. 

Castration  is  necessary  in  most  advanced  cases,  and  should  always  be 
done  when  the  body  of  the  testis  is  involved.  Without  question  it  gives 
a  somewhat  greater  assurance  of  cure,  although  it  often  seems  desirable 
to  run  a  slight  risk  in  this  regard  in  an  attempt  to  save  a  portion  of  the 
testis,  especially  when  one  organ  has  already  been  lost.  The  force  of  this 
statement  is  apparent  when  we  remember  that  orchiectomy  can  be  done 
later  if  necessary. 

There  is  no  question  that  the  removal  of  a  tuberculous  focus  in  one 
testicle  lessens  the  danger  of  disease  in  the  other;  but  that  castration  has 
any  advantage  over  epididymectomy  in  this  regard  has  not  been  proved. 
The  proportion  of  permanent  cures  following  castration  lies  somewhere 
between  40  per  cent  and  60  per  cent.  That  the  cures  from  epididymec- 
tomy, in  well-selected  cases,  are  much  less  than  this  has  not  been  demon- 
strated, and  is  not  probable. 

The  technic  of  castration  is  of  the  utmost  importance.  The  vas  must 
always  be  followed  to  its  exit  from  the  internal  ring,  splitting,  for  this 


784  TUBERCULOSIS  OF   THE   GENITO-URINARY   SYSTEM 

purpose,  the  aponeurosis  of  the  external  ohlique,  as  in  an  operation  for 
hernia,  so  as  to  expose  the  inguinal  canal  freely.  With  a  piece  of  gauze 
the  peritoneum  is  then  stripped  back  and  the  vas  pulled  out  of  the  ring 
as  far  as  possible  before  its  ligation  and  division.  The  lumen  of  the 
stump  should  be  treated  with  carbolic  acid  or  the  actual  cautery.  Von 
Biinger's  suggestion,  that  the  vas  be  pulled  out  until  it  gives  way  at 
some  point  higher  than  could  otherwise  be  reached,  has  not  been  exten- 
sively adopted,  for  fear  of  hemorrhage,  or  of  tearing  the  peritoneum  and 
giving  rise  to  tuberculous  peritonitis.  Although  these  dangers  are  prob- 
ably small,  it  is  nevertheless  true,  as  observed  l)y  the  writer,  that  the 
duct  is  apt  to  give  way  at  a  point  weai<ened  by  disease,  so  that  little,  if 
anything,  is  really  gained  (Plate  III). 

In  advanced  cases,  where  the  scrotum  is  adherent  and  tul^erculous, 
the  greatest  care  must  be  used  to  remove  all  suspicious  tissue  in  order 
to  avoid  recurrence.  This  sometimes  necessitates  the  resection  of  prac- 
tically one  half  of  the  scrotum,  it  being  better  to  remove  too  much  than 
too  little.  Even  after  the  most  careful  operation,  sinuses  of  more  or  less 
importance  may  develop,  but  they  usually  heal  spontaneously. 

Following  castration,  when  healing  has  been  definitely  obtained,  a 
quantity  of  paraffin  may  be  injected  into  the  scrotal  tissues  so  as  to  simu- 
late the  absent  testis,  and  to  some  patients  this  is  a  source  of  much  con- 
solation. 

Whether  much  is  gained  by  following  the  disease  into  the  seminal 
vesicles  and  prostate  is  open  to  discussion.  The  operations  for  this  pur- 
pose are  so  extensive  and  severe,  and  the  good  to  be  obtained  so  prob- 
lematical, that  most  surgeons  hesitate  to  undertake  them,  especially  as 
improvement  often  results  from  orchiectomy  or  epididymectomy  alone. 
The  injection  of  an  emulsion  of  iodoform  into  the  seminal  vesicle 
through  the  lumen  of  the  severed  vas  can  do  no  harm,  and  may  be  of 
service. 


TUBERCULOSIS   OF  THE   SEMINAL  VESICLES  AND   PROSTATE 

It  was  formerly  thought  that  tuberculosis  of  these  organs  was  usually 
primary,  but  the  experiments  of  Baumgarten  and  the  clinical  observa- 
tions of  von  Bruns,  and  others,  seem  to  show  that  it  nearly  always 
ascends  through  the  vas  deferens  from  the  epididymis.  Less  frequently 
it  may  directly  extend  from  the  bladder,  following  renal  tuberculosis. 
The  improvement  which  so  often  follows  castration  is  certainly  sug- 
gestive of  the  secondary  nature  of  the  disease.  Infection  of  the  blad- 
der from  the  seminal  vesicles  and  prostate  sometimes  occurs  in 
advanced  cases,  although  vesical  tuberculosis  generally  descends  from 
the  kidneys. 


TUBERCULOSIS   OF   THE    KIDNEY  785 

Symptoms. — These  may  be  comparatively  slight,  unless  the  posterior 
urethra  is  involved,  when  frequent  and  painful  urination  occurs.  Pus 
often  is  present  in  the  urine,  although  tubercle  bacilli  may  be  difficult  to 
find.  The  usual  signs  of  chronic  seminal  vesiculitis  are  present,  such  as 
irritation  of  the  neck  of  the  bladder,  pain  in  the  rectum,  perineum  and 
back,  together  with  various  nervous  phenomena,  more  or  less  pronounced. 
A  small  amount  of  purulent  urethral  discharge  is  often  observed,  which 
may  contain  bacilli. 

Indurations  can  l)e  felt  in  the  prostate  and  seminal  vesicles,  the  latter 
being  sometimes  greatly  distended  by  tuberculous  material.  Abscesses 
may  develop  in  the  prostate  and  discharge  themselves  into  the  urethra  or 
into  the  bowel,  or  through  the  skin  near  the  anus,  simulating  an  ordinary 
ischiorectal  abscess. 

Treatment. — Treatment  should  generally  be  initiated  by  the  removal 
of  the  tuberculous  focus,  which  usually  exists  in  the  testicle,  by  epididy- 
mectomy  or  castration,  this  being  often  followed  by  more  or  less  rapid 
improvement.  If  abscesses  form,  it  may  be  advisable  to  open  and  thor- 
oughly curette  these  through  the  perineum,  although  annoying  sinuses 
are  apt  to  develop  and  persist  indefinitely.  Prostatectomy  is  occasionally 
resorted  to,  but  is  of  doubtful  utility  in  most  cases,  as  the  wound  often 
becomes  tuberculous  and  refuses  to  heal,  thus  leading  to  incontinence  of 
urine.  The  removal  of  tuberculous  seminal  vesicles  has  been  strongly 
advocated  from  various  sources  during  recent  years,  some  choosing  the 
abdominal  route,  others  the  perineal,  and  still  others  the  sacral ;  but  the 
operations  are  so  severe,  and  the  outlook  for  success  comparatively  so 
poor,  that  most  surgeons  hesitate  to  advise  these  procedures,  except  in 
occasional  cases  and  under  particular  circumstances. 

Local  medication  through  the  urethra,  or  by  means  of  urinary  anti- 
septics, is  of  no  service;  but  hygienic  measures  should  always  be  em- 
ployed, and  an  appropriate  climate  is  undoubtedly  l)eneficial.  Th©wvac- 
cine  therapy  of  Wright  should  be  considered,  although  its  reliability  has 
not  been  proved. 

TUBERCULOSIS    OF    THE    KIDNEY 

The  attention  which  has  recently  been  given  to  renal  tul)erculosis  has 
shown  this  disease  to  be  more  frequent  than  was  formerly  supposed. 
Senn  estimated  that  one  out  of  every  eighteen  consumptives  suffers  from 
some  form  of  genito-urinary  tuberculosis,  and  in  the  Pathologic  Institute 
at  Prague  foci  were  demonstrated  in  the  kidneys  in  5.6  per  cent  of  the 
autopsies  on  adult  tuberculous  patients.  The  percentage  in  children, 
according  to  Gillet  and  Barthez,  is  15.7. 

That  the  disease  is  sometimes  primary  in  the  kidneys  cannot  be  de- 


786  TUBERCULOSIS   OF   THE   GENITO-URINARY   SYSTEM 

nied ;  but,  in  the  great  majorit}^  of  instances,  it  is  undoubtedly  secondary 
to  pulmonary  or  other  foci,  which  are  frequently,  however,  slight  in 
degree  or  latent. 

Little  is  definitely  known  as  to  why  tuberculosis  should  locate  itself 
in  the  kidney  in  one  case  and  not  in  another.  Traumatism,  however, 
may  play  a  part ;  and  it  has  been  noted  that  the  disease  is  apt  to  appear 
in  kidneys  which  are  abnormally  movable,  although  this  is  by  no  means 
always  true.  The  writer  has  noticed  the  frequency  with  which  the 
trouble  seems  to  occur  in  so-called  latent  pulmonary  tuberculosis;  but 
this  may  be  more  apparent  than  real,  because  in  marked  pulmonary  in- 
volvement attention  is  concentrated  on  the  lungs  to  the  neglect  of  other 
lesions. 

Pathology. — The  hematogenous  origin  of  tuberculosis  of  the  kidneys 
is  now  commonly  recognized,  contrary  to  the  older  idea  that  infection 
took  place  through  the  ureters.  This  modern  view  is  well  expressed  by 
Schede,  who  says,  "  It  has  been  proved  beyond  all  doubt,  and  is  generally 
accepted,  that  the  principal  mode  of  infection  is  through  the  blood." 
Clinical  experience  is  furthermore  strongly  supported  by  the  interesting 
experiments  of  Baumgarten  already  referred  to  (see  page  778). 

When  the  disease  is  not  part  of  a  general  miliary  tuberculosis,  it 
almost  always  begins  in  one  kidney.  Israel  estimates  that  this  is  true  in 
ninety  per  cent  of  the  cases,  while  others  place  the  proportion  still  higher. 
This  has  been  learned  at  the  postmortem  table  rather  than  in  the  oper- 
ating room,  for  by  the  time  a  case  comes  to  autopsy  the  second  kidney 
may  have  become  infected  through  tlie  blood,  or  through  the  bladder 
from  the  kidney  first  involved.  This  unilateral  origin  is  of  the  utmost 
importance  as  regards  surgical  treatment. 

The  parenchyma  is  usually  affected  first,  often  just  beneath  the  cap- 
sule, and  from  here  the  disease  spreads  downward  to  the  pyramids,  pelvis, 
ureter,  and  bladder,  with  more  or  less  rapidity.  It  may  be  disseminated 
throughout  the  kidney,  which  is  generally  the  case,  or  confined  to  some 
particular  portion.  Smaller  nodules  combine  to  form  larger  ones,  which 
undergo  caseation  and  lead  to  the  development  of  tuberculous  abscesses, 
perhaps  of  large  size  (Plate  III,  Fig.  1).  In  advanced  cases  the  whole 
organ  may  be  little  more  than  a  sac  containing  caseous  material  and 
pus.  Perinephritis  is  not  uncommon,  and  is  sometimes  of  that  variety 
in  which  the  kidney  becomes  embedded  in  a  thick  mass  of  dense  fibrous 
tissue.  Perforation  of  the  capsule  may  lead  to  perinephritic  abscesses, 
often  multiple,  and  sometimes  of  great  size. 

Involvements  of  the  pelvis  present  themselves  as  ulcerations  of  a 
characteristic  tuberculous  appearance.  Disease  of  the  ureter  manifests 
itself  by  thickening  of  the  wall  and  ulceration  of  the  lining  membrane, 
but  strictures  seldom  result. 


PLATE    III 


% 


N. 


# 


^ 


1.— tl-bercvlosis  of  the  kidxey,  showing  cavities  and  nodcles. 

2.— Tuberculosis  of  Lymph-node,  showing  Caseous  Nodules. 

3— Tuberculosis  of  Epididymis,  Incision  through  Normal  Body  of  the  Testis. 


TUBERCULOSIS  OF  THE   KIDNEY  787 

Symptoms. — These  are  often  so  surprisingly  slight,  unless  secondary 
infection  occur,  that  the  disease  may  be  overlooked  until  it  is  far  ad- 
vanced. There  may  be  no  pain  or  discomfort  of  any  kind  as  far  as  the 
kidneys  are  concerned,  the  first  manifestation  of  the  disease  being  felt 
in  the  bladder  or  observed  in  the  cloudy  or  bloody  urine,  which  was  well 
illustrated  in  the  case  from  which  the  kidney  shown  in  Plate  III,  Fig.  1 
was  obtained.  Often  the  bladder  is  treated  for  a  long  time  before  the 
kidneys  are  suspected.  Even  the  urine  may  give  no  indication  of  what  is 
going  on,  because  the  disease  is  confined  to  the  parenchyma  without  in- 
vasion of  the  pelvis.  The  writer  has  seen  extensive  involvement  of  the 
kidney,  with  an  abscess  as  large  as  a  walnut,  while  the  urine  remained 
jjerfectly  normal. 

As  a  rule,  however,  more  or  less  pronounced  pain  and  tenderness  are 
felt  about  the  kidney  and  along  the  ureter,  with  occasional  attacks  of 
spasmodic  renal  colic.  Eeflex  pain  may  be  felt  in  the  bladder,  testicle, 
or  thigh,  often  leading,  in  the  case  of  the  bladder,  to  unnecessary  opera- 
tions and  prolonged  treatment  before  the  real  seat  of  the  disease  is  dis- 
covered. 

The  urine  nearly  always  shows  characteristic  changes.  It  is  usually 
watery  in  color,  abundant,  and  of  low  specific  gravity.  In  fact,  a  "  dia- 
betes insipidus,"  especially  in  early  and  middle  life  and  in  those  with 
suspicious  histories,  should  always  direct  attention  to  possible  tubercu- 
losis of  the  kidneys.  Pus  is  always  present  when  the  kidney  lesion  com- 
municates with  the  pelvis,  and  when  it  is  present  in  sufficient  quantity 
it  causes  a  uniform  cloudiness  of  the  urine.  The  reaction  is  acid,  except 
in  the  presence  of  certain  mixed  infections.  It  must  be  distinctly  under- 
stood, however,  that  the  character  of  the  urine  is  but  a  poor  index  to  the 
extent  of  the  disease,  because  the  kidney  may  contain  many  small  and 
even  large  abscesses  which  have  no  connection  with  the  channel  of  ex- 
cretion. Blood  is  often  seen  in  the  urine,  either  microscopically  or 
macroscopic-ally;  in  fact,  decided  renal  hemorrhages  are  not  infrequent, 
and  may  even  be  the  first  symptom  to  attract  attention.  Urinary  casts 
are  not  found  as  often  as  might  be  expected,  and  particles  of  caseous  ma- 
terial are  encountered  in  advanced  cases  only. 

The  demonstration  of  tubercle  bacilli  is  not  easy,  even  when  the  dis- 
ease is  marked  and  the  urine  full  of  pus ;  for  instance,  none  were  found 
in  the  urine  coming  from  the  kidney  illustrated  in  Plate  III,  Fig.  1. 
Repeated  and  careful  search  is  necessary,  by  the  most  a  improved  methods, 
carried  out  with  due  reference  to  possible  confusion  with  the  smegma 
bacillus.  It  is  better  to  centrifugate  the  entire  urine  for  twenty-four 
hours,  according  to  the  Forsell-Gregerson  method,  than  it  is  to  depend  on 
a  single  specimen.  The  apparent  absence  of  bacilli  should  not  influence 
the  diagnosis  too  strongly.     In  fact,  a  good  rule  to  follow  is  to  regard 


788  TUBERCULOSIS   OF   THE  GENITO-URINARY   SYSTEM 

every  chronic  inflammation  of  tlie  bladder  as  tuberculous,  especially  in 
early  and  middle  life,  unless  it  can  be  proved  to  be  due  to  other  causes. 
Even  the  history  of  a  recent  gonorrhea  should  not  be  given  too  much 
weight,  as  this  disease  seems  frequently  to  prepare  the  soil  for  a  subse- 
quent tuberculosis. 

Mixed  infection  is  common,  especially  with  the  colon  bacillus  and 
the  pus-forming  microorganisms,  and  may  be  regarded  as  the  source  of 
much  of  the  pain  and  discomfort.  It  may  occur  spontaneously  or  be 
caused  by  instrumentation. 

The  general  symptoms  are  not  marked  at  first,  although  a  slight  even- 
ing rise  in  temperature  may  exist,  with  a  corresponding  fall  to  subnormal 
in  the  morning;  but  in  advanced  cases,  especially  those  with  marked  in- 
volvement of  the  bladder,  emaciation  exists,  accompanied  by  constitu- 
tional disturbances  due  to  sepsis,  pain,  strangury,  and  loss  of  sleep,  the 
condition  of  such  patients  being  pitiable  in  the  extreme.  In  spite  of  the 
fact  that  the  disease  somietimes  becomes  latent  for  longer  or  shorter 
periods,  and  occasionally  disappears  without  treatment,  the  large  ma- 
jority of  cases  pass  from  bad  to  worse,  with  all  the  suffering  incident  to 
renal  degeneration  and  harassing  cystitis,  until  death  affords  relief.  It 
should  be  noted,  however,  that  much  of  the  actual  suffering  -usually 
comes  not  so  much  from  the  kidneys  as  from  the  bladder. 

Diagnosis. — This  is  made  by  taking  into  consideration  the  history  of 
the  patient;  the  watery,  acid,  purulent  urine  containing  tubercle  bacilli 
and,  perhaps,  blood ;  the  ulcerated  condition  of  the  bladder,  and  the  pres- 
ence of  tuberculosis  in  the  lungs,  testicles,  seminal  vesicles,  or  prostate. 

There  is  often  much  diagnostic  confusion  between  tuberculosis  and 
stone,  particularly  in  early  stages  of  the  disease  and  when  nephritic  colic 
exists.  The  intelligent  employment  of  the  X-ray  is  then  of  the  greatest 
importance,  and  much  dependence  may  be  placed  on  the  conclusions  thus 
obtained.  If  the  tubercle  bacillus  cannot  be  detected  microscopically, 
animal  inoculation  should  l^e  tried.  There  is  always  much  uncertainty 
regarding  the  use  of  tuberculin  for  diagnostic  purposes,  owing  to  the 
usual  presence  of  pulmonary  tuberculosis. 

The  hemorrhage  from  malignant  tumors  and  from  certain  forms  of 
chronic  interstitial  nephritis  may  lead  to  mistakes  in  diagnosis,  if  the 
character  of  the  urine  is  not  repeatedly  observed,  and  the  bladder  and 
mouth  of  the  ureters  carefully  inspected  with  the  cystoscope. 

Treatment. — Internal  medication  is  of  little  or  no  value,  unless  the 
vaccine  therapy  of  Wright,  which  is  at  present  attracting  so  much  atten- 
tion, prove  to  be  of  more  service  than  is  now  accorded  it.  The  ordinary 
urinary  antiseptics  often  do  more  harm  than  good.  General  hygienic 
measures,  combined  with  outdoor  life  in  an  appropriate  climate,  are  cer- 
tainly of  some  use,  although  they  cannot  be  depended  on  and  should  not 


TUBERCULOSIS   OF   THE    KIDNEY  789 

be  persisted  in  to  the  exclusion  of  surgical  intervention,  if  improvement 
is  not  rapidly  obtained. 

The  accumulated  evidence  of  many  observers  has  demonstrated  that 
early  nephrectomy,  before  involvement  of  the  bladder  occurs,  is  the  best 
treatment  for  unilateral  renal  tuberculosis,  provided  the  general  condi- 
tion of  the  patient  permit.  It  is  not  even  permissible  to  temporize  long 
with  what  appear  to  be  mild  or  incipient  cases,  as  the  symptoms  form  an 
unreliable  index  to  the  extent  of  the  disease,  and  while  expectant  treat- 
ment is  being  used,  the  trouble  is  often  secretly  progressing.  Tubercu- 
losis elsewhere,  if  not  too  far  advanced,  is  not  a  contraindication  to  oper- 
ation, because  subsequent  improvement  often  results.  Especially  is  this 
true  of  the  bladder,  which  may  get  better  or  recover,  even  in  bad  cases, 
after  removal  of  the  source  of  infection.  An  extreme  instance  is  re- 
ported by  Kiimmel,  in  which  there  was  present  tuberculosis  of  both  testi- 
cles, both  seminal  vesicles,  the  bladder,  and  both  kidneys,  together  with 
pulmonary  tuberculosis  and  a  tnbercnlons  periurethral  abscess,  the  pa- 
tient suffering  great  pain  and  prostration.  The  trouble  seeming  to  center 
in  the  left  kidney,  this  was  removed.  Immediately  a  marked  improve- 
ment took  place,  the  patient  being  relieved  sufficiently  to  return  to  his 
work. 

The  principal  thing  to  be  kept  in  view  when  considering  nephrectomy 
is  the  condition  of  the  second  kidney,  which  must  be  functionally  sound, 
although  the  mere  existence  of  albumen  and  casts  does  not  necessarily 
contraindicate  operation,  provided  the  excretory  power  is  good,  because 
they  may  be  due  to  the  presence  of  toxins  in  the  blood,  and  will  disappear 
after  the  tuberculous  organ  is  removed.  As  a  rule  the  other  kidney 
should  be  free  from  tuberculosis,  although  there  is  considerable  clinical 
evidence  to  show  that,  even  when  both  organs  are  diseased,  the  removal 
of  the  one  which  is  most  affected  may  have  a  favorable  action  on  the  re- 
maining one.  The  weight  of  evidence  is  against  partial  nephrectomy, 
however  enticing  it  may  appear  in  theory,  for  it  is  impossible  to  be  sure 
that  all  the  disease  has  been  eradicated,  owing  to  its  frequent  dissemina- 
tion in  small  and  widely  scattered  foci.  Nevertheless,  it  is  interesting  to 
note  that  Morris  successfully  excised  a  tuberculous  focus  from  the  kid- 
ney of  a  woman  whose  other  kidney  had  previously  been  removed  for  the 
same  disease. 

Nephrotomy  is  never  indicated,  except  for  the  purpose  of  relieving 
great  suffering  in  those  who  for  some  reason  cannot  undergo  nephrec- 
tomy. A  cure  cannot  be  expected,  and  a  troublesome  urinary  sinus 
results. 

Following  nephrectomy,  tuberculous  fistulae  often  persist  in  connec- 
tion with  the  end  of  the  infected  ureter.  Hence,  theoretically,  removal  of 
the  entire  tube  is  indicated,  as  practiced  l)y  Kelly  and  Hunner.     Prac- 


790  TUBERCULOSIS  OF   THE   GENITO-URINARY   SYSTEM 

tically  this  is  not  advisable,  as  it  increases  the  extent  and  danger  of  the 
operation;  and,  in  addition,  the  fistulae  usually  disappear  spontaneously 
in  the  course  of  time,  although  they  often  persist  for  many  months.  It 
is  desirable,  however,  to  cauterize  the  lumen  of  the  ureter  and  fasten  the 
stump  in  the  lower  angle  of  the  wound,  where  it  can  be  reached  easily, 
and  where  it  will  do  the  least  damage.  Mayo  advises  the  injection  of  a 
small  amount  of  ninety-five-per-cent  carbolic  acid  into  the  ureter,  in 
order  to  disinfect  it  as  far  as  possible. 

In  considering  the  question  of  operation,  the  most  important  points 
are:  (1)  Whether  the  disease  is  unilateral  or  bilateral;  (2)  if  unilateral, 
which  kidney  is  affected;  and  (3)  is  the  second  kidney  capable  of 
properly  performing  its  function  if  a  nephrectomy  is  done?  In  coming 
to  reliable  conclusions,  the  catheterizing  cystoscope  is  almost  indispensa- 
ble. With  it  can  be  noted  the  condition  of  the  bladder,  and  particularly 
the  appearance  of  the  ureteral  openings.  If  the  mouth  of  a  ureter  is 
swollen  and  red,  and  particularly  if  it  is  ulcerated,  the  corresponding 
kidney  is  almost  certainly  tuberculous.  Sometimes  blood  or  pus  can  be 
seen  coming  from  the  orifice.  Catherization  of  the  ureters  furnishes  evi- 
dence regarding  nephritic  conditions,  and  is  practically  devoid  of  danger 
of  carrying  infection  to  a  sound  kidney  if  the  l)ladder  is  thoroughly  irri- 
gated and  proper  aseptic  precautions  are  employed.  The  Harris  and 
Luys  segregators  are  also  of  service,  and  may  be  used  in  place  of  the 
cystoscope,  in  many  instances,  although  their  use  is  more  painful,  espe- 
cially in  the  male,  and  the  results  are  not  so  reliable. 

When  the  bladder  is  irrita1)le,  ulcerated,  and  perhaps  shrunken,  a 
segregator,  or  even  at  times  a  cystoscope,  cannot  be  employed.  A  general 
anesthetic,  or  spinal  anesthesia,  can  then  be  considered,  but  this  may 
also  fail  when  the  vesical  conditions  are  particularly  bad.  Under  these 
circumstances  it  has  ])een  advised  to  open  the  bladder  above  the  pubes, 
and  catheterize  the  ureters  by  direct  observation ;  but  a  better  plan,  which 
is  open,  however,  to  error,  is  to  make  an  exploratory  incision  over  each 
kidney  with  the  idea  of  removing  the  diseased  organ  at  once,  provided 
the  other  seems  to  be  sound   (Edebohls  and  Eovsing). 

Many  methods  have  been  suggested  for  determining  the  functionating 
power  of  the  second  kidney,  but  none  of  them  is  entirely  reliable.  In 
fact,  so  eminent  an  authority  as  Eovsing  has  discarded  them  all  in  favor 
of  the  simple  estimation  of  the  solids,  especially  the  urea.  There  are 
others,  however,  who  claim  great  corroborative  reliability  for  various 
tests.  Cryoscopy,  for  instance,  has  been  extensively  employed.  It  con- 
sists in  the  determination  of  the  relative  density  of  the  blood  or  urine  by 
ascertaining  the  freezing  point  by  means  of  appropriate  apparatus.  The 
temperature  at  which  the  blood  should  normally  congeal  is  0.56°  C.  to 
0.57°  C.     A  freezing  point  of  less  than  0.0°  C.  means  that  the  second 


TUBERCULOSIS   OF   THE   BLADDER  791 

kidney  is  not  exerting  its  proper  function,  and  a  nephrectomy  would  be 
dangerous.  Similar  conclusions  may  be  drawn  from  cryoscopy  of  the 
separated  urines. 

The  renal  excretory  power  may  also  be  approximated  with  an  accuracy 
that  compares  favorably  with  that  of  cryoscopy  by  feeding  the  patient 
a  quantity  of  salt,  and  then  determining  the  percentage  of  sodium  chlorid 
in  the  blood  or  urine,  which  approximately  corresponds  to  the  amount  of 
urea.  This  is  determined  by  noting  the  hemolytic  action  of  the  blood 
serum  or  urine  on  the  red  corpuscles  of  normal  blood  (Wright).  An 
increase  of  salt  in  the  blood,  or  a  decrease  below  two  per  cent  in  the 
urine,  would  indicate  diminution  in  the  fimction  of  the  kidneys. 

Experience  has  shown  that  but  little  confidence  can  be  placed  on  the 
determination  of  the  excretory  capacity  of  the  kidneys  by  the  color  of 
the  combined  or  separated  urines  after  the  administration  of  indigo  car- 
mine or  methylene-blue.  The  phloridzin  test,  based  on  finding  sugar  in 
the  urine  at  varying  intervals  after  the  administration  of  the  drug,  is 
also  unreliable.  These  various  methods  may  be  of  service,  however,  as 
corroborative  evidence. 

TUBERCULOSIS  OF  THE  SUPRARENAL  GLAND 

This  form  of  tul)erculosis  is  uncommon,  and  may  exist  with  or  with- 
out involvement  of  the  kidney.  When  the  function  of  the  glands  is  suffi- 
ciently destroyed,  pigmentation  of  tlie  skin,  gastro-intestinal  symptoms, 
and  asthenia  may  result  (Addison's  disease).  If  the  diagnosis  can  be 
made,  extirpation  of  the  gland  is  the  best  treatment. 

TUBERCULOSIS    OF    THE    BLADDER 

Tuberculosis  of  the  bladder  is  seldom  primary ;  in  tlie  vast  majority 
of  instances  it  descends  from  the  kidneys,  and  occasionally  ascends  from 
the  epididymis.  In  some  instances,  however,  when  the  bladder  is  already 
extensively  involved,  the  disease  may  creep  upward  through  a  dilated 
ureter  to  a  sound  kidney  (Eovsing). 

Symptoms. — The  primary  disease  of  the  kidney  is  frequently  so  in- 
'sidious  and  so  free  from  objective  and  subjective  symptoms  as  to  be 
overlooked,  and  the  entire  attention  of  physician  and  patient  is  given 
to  the  bladder.  Hence  the  rule  that  in  every  case  of  tuberculosis  of 
the  bladder,  the  condition  of  the  kidneys  must  be  thoroughly  investi- 
gated. This  is  best  done  with  the  catheterizing  cystoscope;  but  as  a 
rough  preliminary  test,  the  bladder  may  be  cleansed  thoroughly  by 
copious  irrigations,  and  the  urine  collected  within  fifteen  to  thirty  min- 
utes.   Under  these  circumstances  l)ut  little  \ms  will  have  had  time  to  form 


792  TUBERCULOSIS  OF   THE   GENITO-URINARY   SYSTEM 

in  the  bladder,  and  if  the  urine  is  still  nearly  as  cloudy  as  it  was  before, 
it  is  fair  to  conclude  that  the  contamination  is  probably  of  renal  origin. 

The  reflex  phenomena  are  similar  to  those  which  are  met  with  in 
other  forms  of  kidney  lesions,  and  are  often  misleading  as  to  the  loca- 
tion of  the  disease.  In  addition,  irritative  and  inflammatory  conditions 
may  arise  from  the  passage  of  contaminated  urine  through  the  bladder, 
and  are  difficult  to  differentiate  from  actual  tuberculous  troulfles.  They 
quickly  disappear,  however,  when  the  source  of  contamination  is  re- 
moved. 

Tuberculous  ulcerations,  beginning  with  the  deposition  of  tubercles, 
usually  start  in  the  mucosa  surrounding  the  mouth  of  a  ureter.  The 
orifice  stands  open,  and  appears  red  and  swollen,  and  later  ulcerated. 
Gradually  the  disease  spreads  over  the  trigonum,  and  may  ultimately 
involve  a  large  portion  of  the  bladder.  The  symptoms  are  those  of 
cvstitis.  They  are  at  first  slight,  manifesting  themselves  in  moderate 
irritation  and  frequency  of  urination;  Init  as  the  disease  progresses  the 
inconvenience  and  suffering  increase,  especially  if  mixed  infection  occurs, 
until  the  patient  becomes  worn  out  and  emaciated  from  pain,  strangury, 
and  loss  of  sleep.  The  bladder  may  become  so  shrunken  that  it  will 
contain  but  a  few  drachms  of  purulent  and  bloody  urine,  which  burns  the 
urethra  in  its  passage.  There  are  few  more  pitiable  objects  than  a 
patient  in  this  unfortunate  condition. 

Sometimes  the  course  of  the  disease  is  rapid,  but  usually  it  is  quite 
slow,  occupying  months  or  even  years  in  its  development ;  but  whether 
slow  or  rapid,  it  usually  ends  in  disaster,  although  long  periods  of 
latency  or  even  permanent  cures  are  occasionally  seen. 

Diagnosis. — In  tuberculous  cystitis,  the  wrong  diagnosis  is  so  often 
made  that  it  is,  perhaps,  best  to  regard  every  chronic  inflammation  of 
the  bladder  in  young  and  middle-aged  individuals  with  suspicion  unless 
its  origin  is  perfectly  clear.  The  fact  that  the  patient  has  had  gonorrhea 
is  not  conclusive  evidence  that  he  may  not  have  tuberculosis,  and  the 
same  may  be  said  of  vesical  calculus.  The  tubercle  bacillus  should  al- 
ways be  sought  for,  but  its  apparent  absence  should  not  be  taken  into 
account  too  strongly.  The  inoculation  of  animals  is  much  more  certain 
than  the  use  of  the  microscope.  Ulcerations  about  the  mouth  of  the 
ureters  and  in  the  trigonum  can  often  be  seen  with  the  cystoscope.  A 
watery,  acid  urine,  containing  pus  but  apparently  no  bacteria,  is  very 
characteristic,  but  alkalinity  of  the  urine  and  the  presence  of  numerous 
microorganisms  often  exist  with  tuberculosis,  owing  to  mixed  infection. 
The  existence  of  tuberculosis  of  the  lungs,  testicles,  seminal  vesicles,  or 
prostate  may  throw  miich  light  on  the  condition. 

Treatment. — The  first  step  in  the  treatment  of  tuberculosis  of  the 
bladder,  when  the  disease  has  descended  from  a  single  kidney,  should 


TUBERCULOSIS  OF   THE   BLADDER  793 

be  nephrectomy,  when  the  general  condition  of  the  patient  and  the  func- 
tionating powers  of  the  other  kidney  permit.  Without  removing  the 
source  of  the  trouble,  all  efforts  at  treatment  are  generally  unsuccessful, 
but  following  nephrectomy,  a  cure,  or  at  least  improvement,  may  con- 
fidently be  expected.  It  is  gratifying  to  note  how  completely  even  severe 
lesions  of  the  bladder  will  disappear  after  removal  of  a  diseased  kidney — 
lesions  which  had  long  resisted  other  forms  of  treatment  and  which  a 
short  time  ago  were  regarded  as  incurable.  It  is  self-evident  that  the 
sooner  the  operation  is  done  the  more  satisfactory  will  be  the  result; 
hence,  early  diagnosis  and  early  operation  cannot  be  urged  too  strongly. 

Operations  on  the  bladder  itself,  such  as  curettement,  cauterization, 
and  excision  of  ulcers,  without  reference  to  the  kidneys,  are  almost  use- 
less, because  of  the  likelihood  of  reinfection.  Permanent  suprapubic 
drainage  may  occasionally  be  desirable  for  palliation  of  symptoms  where 
both  kidneys  are  badly  diseased  or  some  other  contraindication  to 
nephrectomy  exists.  Removal  of  the  bladder  for  tuberculosis  should 
seldom,  if  ever,  be  done. 

Local  treatments  by  irrigation  are  of  but  little  service,  and  are  often 
harmful.  When  inserting  instruments  into  the  bladder,  the  most  ex- 
treme care  must  always  be  employed  to  avoid  the  production  of  mixed 
infection.  Solutions  of  nitrate  of  silver  and  potassium  permanganate, 
which  are  so  useful  in  ordinary  cystitis,  only  increase  the  irritation  in 
the  tuberculous  forms.  Much  use  has  been  made  of  injections  of  a  ten- 
per-cent  emulsion  of  iodoform  in  olive  oil.  This  floats  on  the  surface 
of  the  urine,  and  the  patient  endeavors  to  retain  the  material  in  the 
bladder  as  long  as  possible  by  carefully  passing  his  urine  from  beneath 
it.  Although  decrease  of  bladder  irritation  can  sometimes  be  obtained 
in  this  way,  the  process  can  seldom  result  in  cure,  and  has  been  largely 
discarded. 

Quite  recently  Rovsing  has  recommended  a  method  of  treatment,  the 
principal  indications  for  which  exist  in  those  cases  of  ulceration  which 
are  primary  or  which  stubbornly  persist  following  a  nephrectomy.  His 
instructions  are :  "  After  washing  the  bladder  free  from  pus,  50  e.c.  of 
a  warm,  freshly  prepared,  six-per-cont  solution  of  carbolic  acid  are  in- 
jected. The  solution  is  retained  three  or  four  minutes,  when  it  returns 
through  the  catheter  quite  milky  in  color.  This  is  repeated  three  or 
four  times,  imtil  the  fluid  returns  fairly  clear,  after  which  there  should 
be  no  further  irrigation.  In  order  to  lessen  the  pain,  which  is  severe 
for  two  or  three  hours,  a  rectal  suppository  is  employed,  containing 
about  one  third  of  a  grain  of  morphin."  The  treatment  is  repeated 
every  second  day  at  first,  and  then  the  intervals  are  lessened  until  a 
cure  results,  whicli  r(H|iiires  at  least  a  mouth,  and  often  much  longer. 
Fourteen  out  of  nineteen  cases  were  cured  in  this  way. 


794  TUBERCULOSIS  OF   THE   GENITO-URINARY   SYSTEM 

TUBERCULOSIS    OF    THE    URETHRA 

Tuberculosis  of  the  urethra  generally  occurs  as  an  extension  from 
the  bladder,  although  it  may  arise  from  disease  of  the  prostate  or 
seminal  vesicles.  It  seldom  attacks  the  anterior  portion  of  the  canal. 
Little  can  be  done  in  the  way  of  treatment  except  the  removal  of  the 
source  of  infection,  which  is  usually  effective. 

TUBERCULOSIS  OF  THE  GENITAL  TRACT  IN  WOMEN 

Like  other  forms  of  genito-urinary  tuberculosis,  this  is  almost  always 
secondary  to  tuberculosis  in  other  regions  of  the  body.  It  usually  orig- 
inates in  the  tubes,  where  the  arrangement  of  the  capillary  circulation 
favors  the  localization  of  bacilli,  although  it  may  appear  first  in  the 
ovaries,  especially  in  children.  From  the  tubes  the  disease  frequently 
invades  the  peritoneum,  the  uterus,  and  occasionally  the  vagina.  It 
rarely,  if  ever,  appears  in  the  two  last-named  structures,  except  as  a 
descending  infection. 

Pathology. — The  pathologic  lesions  are  those  of  tul)erculosis  else- 
where— small  and  large  tubercles,  ulceration,  caseation,  and  the  forma- 
tion of  tuberculous  pus  with  which  tubes  or  ovaries  may  become  dis- 
tended. The  uterine  cavity  can  exhibit  extensive  ulcerative  or  caseous 
changes,  or  it  may  be  filled  with  so-called  tuberculous  granulations.  The 
cervix,  although  rarely  attacked,  may  ulcerate  or  become  the  seat  of 
"  tubercular  fungus "  in  the  shape  of  exuberant  gi-anulations.  When 
the  vagina  is  affected,  which  is  uncommon,  it  is  usually  in  the  form 
of  ulceration. 

Symptoms  and  Diagnosis. — The  symptoms  resemble  so  closely  those 
of  other  inflammatory  lesions  that  the  diagnosis  is  always  difficult,  and 
often  impossible,  prior  to  operation.  The  presence  of  tuberculosis  else- 
where— for  instance,  in  the  lungs — especially  in  the  young  and  where 
other  causes  can  be  excluded,  should  excite  suspicion. 

Treatment. — The  essential  feature  in  treatment  is  the  removal  of  the 
original  focus,  which  usually  necessitates  salpingectomy  or  ovariotomy. 
When  this  is  done,  the  associated  structures  which  may  have  become 
involved  secondarily,  such  as  the  peritoneum  and  uterus,  tend  to  im- 
prove spontaneously.  Before  salpingectomy  is  done,  local  treatment  of 
the  uterine  cavity  is  of  little  service,  but  after  a  diseased  tube  has  been 
removed,  thus  cutting  off  renewed  infection  from  above,  an  energetic 
curettement,  followed  by  the  application  of  strong  carbolic  acid  or  tinc- 
ture of  iodin,  will  hasten  recovery.  Hysterectomy  is  seldom  indicated 
unless  extensive  uterine  disease  is  combined  with  tuberculosis  of  both 
tubes. 


ADDENDA 

By  LEONARD  FREEMAN 

Summary  of  Surgical  Tuberculosis,  Presented  at  the  International  Con- 
gress, Jield  in  Washington,  D.  C. 

Although  many  vakiable  and  interesting  contributions  to  the  subject 
of  surgical  tuberculosis  were  presented,  they  were  mostly  in  the  nature 
of  confirmations  of  existing  facts  and  theories. 

The  necessity  for  outdoor  and  climatic  treatment  of  surgical  as  well 
as  of  pulmonary  tuberculosis  was  universally  emphasized,  quite  epigram- 
matically  by  DeForrest  Willard,  who  said  that  "  twenty-five  thousand 
doses  of  pure  air  in  twenty-four  hours  are  infinitely  better  than  three 
doses  of  nauseous  drugs  that  disturb  the  digestion."  It  was  insisted 
upon,  that  although  fresh  air  and  climate  might  not  alone  be  curative 
in  many  cases,  nevertheless  they  must  be  considered  as  extremely  valu- 
able adjuncts  to  the  other  forms  of  treatment. 

In  spite  of  some  encouragement  in  the  treatment  of  tuberculous 
lymph  nodes  of  the  neck  with  the  X-ray  and  with  tuberculin,  opinion 
was  strongly  in  favor  of  operative  intervention.  Dowd  reported  80  per 
cent  of  cures  in  275  operations,  with  an  additional  10  per  cent  of 
improvements,  while  the  mortality  was  but  0.33  per  cent.  Charles  Mayo 
thought  that  operations  could  often  be  avoided  in  children  under  eight 
years  of  age  by  the  removal  of  foci  of  infection  in  the  mouth  and 
pharynx,  together  with  appropriate  hygienic  measures. 

The  numerous  papers  and  discussions  on  renal  and  vesical  tuber- 
culosis (Bevan,  Rovsing,  Illyer,  Ehimor,  Guiteras,  Karo,  etc.)  lay  stress 
upon  the  almost  invariable  hematogenous  origin  of  the  infection,  its 
progression  downward  toward  the  bladder,  and  the  desirability  of  early 
diagnosis  and  immediate  nephrectomy  before  the  occurrence  of  vesical 
involvement. 

The  imreliability  of  the  vaccine  treatment  was  admitted,  Avithont 
losing  sight  of  its  future  possibilities.  It  can  be  employed  with  advan- 
tage in  the  treatment  of  inoperable  cases,  and  as  an  aid  to  satisfactory 
convalescence  after  operation. 

An  important  paper  on  the  prevention,  diagnosis,  and  treatment  of 
tuberculous  sinuses  and  abscess  cavities  was  contributed  by  Emil  G. 
Beck,  of  Chicago.     The  method  consists  in  the  injection  into  the  sinus 

795 


796  TUBERCULOSIS  OF   THE   GENITO-URINARY   SYSTEM 

or  abscess  of  a  paste  composed  of  subnitrate  of  bismuth  (usually  thirty- 
three  per  cent)  and  vaselin.  In  sinuses,  considerable  pressure  is  em- 
ployed during  the  injection  in  order  to  insure  penetration  of  the  mix- 
ture into  the  remotest  parts  of  the  tract.  A  skiagram  will  then  reveal 
the  ramifications  of  the  sinus,  w^hich  are  often  surprising  in  their  extent 
and  complexity.  These  injections  also  seem  to  possess  remarkable  thera- 
peutic properties,  Beck  reporting  65  per  cent  of  cures  in  192  cases,  with 
25.5  per  cent  of  improvements. 

The  opinion  was  generally  expressed  that  the  ocular  and  cutaneous 
tests  for  surgical  tuberculosis  are  of  miich  diagnostic  and  some  prog- 
nostic value,  although  neither  of  them  are  infallible,  being  sometimes 
negative  when  tuberculosis  is  present  and  occasionally  positive  when 
no  tuberculosis  exists.  The  cutaneous  test  (von  Pirquet)  is  probably 
preferable  to  the  conjunctival,  as  it  is  safer  and  at  least  equally  reliable. 
It  was  agreed  that  the  old  subcutaneous  test  should  seldom  if  ever  be 
used,  because  of  the  considerable  risk  attending  such  injections. 

After  referring  to  the  investigations  of  Sauerbruch,  Matas,  and  others 
in  regard  to  operations  upon  the  lungs  under  negative  and  positive 
pressure,  Eobinson,  of  Boston,  perhaps  voiced  the  general  opinion  by 
saying  that  "  it  can  no  longer  be  justly  stated  that  tuberculosis  of  lung 
and  pleura  is  out  of  reach  of  the  surgeon,  but  the  question  remains  an 
open  one  as  to  whether  drainage  or  excision  of  tuberculous  foci  in  the 
thoracic  cavity  can  ever  result  in  the  removal  of  the  infection." 

The  hematogenous  origin  of  tuberculosis  of  the  epididymis  was  em- 
phasized, and  conservative  surgery  (epididymectomy)   advocated. 

The  increasing  conservatism  in  the  treatment  of  joint  tuberculosis 
was  mentioned  and  discussed,  operations  being  much  less  frequent  than 
they  formerly  were,  and  more  and  more  stress  being  laid  upon  such 
measures  as  fresh  air,  climate,  rest,  Bier's  passive  hyperemia,  injections, 
vaccine,  etc. 


APPENDICES 


APPENDIX    I 

THE    TUBERCULO-OPSONIC    INDEX 
By  MARY  C.  LINCOLN,  M.D. 

Private  Lahoratory  of  Dr.  L.  L.  McArthur  and  Dr.  J.   C.   HolUster, 
St.  Luke's  Hospital,  Chicago 

Tech  NIC 

There  is  no  absolute  teclmic  in  the  determination  of  tlie  tuberciilo- 
opsonic  index.  The  index  represents  a  comparison  between  tlie  opsonins 
of  normal  serum  and  those  of  pathological  serum ;  hence,  consistency 
in  teclmic  is  the  real  essential.  Certain  principles  in  the  teclmic  are 
salient,  but  the  details  of  carrying  out  these  principles  must  vary.  Each 
opsonist  works  out  his  own  best  teclmic.  The  following  is  the  technic 
as  developed  in  our  laboratory : 

I.  Blood  Serum: 

1.  Wind    bandage     around    finger     and     make    puncture    in     side    of 
finger    tip    with     fine    point     of    glass    cap- 
sule. 

2.  Break  ofi'  both  tips  of  capsule  (Fig.  1) 
and  allow  three  to  four  large  drops  of  blood 
to  njn  in  through  curved  end  held  immersed 
in  drop  of  blood.  Fig.    L — The    Completed 

3.  Seal  straight  end  of  capsule,  cool,  and  Capsule.     Note  the  fine 
11,111           •    ,           11         1  stabbing  -  point     at     the 

shake  biood  down  into  sealed  end.  ,     •  i  .         ,  ,t^ 

.    T        1  ^  f  •  straight    end  x.      (trom 

4.  Incubate  three  to  four  minutes.  ^  ^^^^^    ^^^^^    ^^^^    g^^^ 

5.  Hang  capsule  by  curved  arm  in  centri-  Dec,  1906.) 
fuge  cup  and  centrifuge  five  minutes. 

6.  Break  oil  curved  end  of  capsule  with  pinchers  and  stand  capsule 
upright  in  sand  box. 

II.  Cream: 

1.  Let  ten  to  twelve  large  drops  of  blood  fall  into  test  tube  (capacity 
4  c.c,  diameter  1  cm.)  three  fourths  full  of  citrate  solution  (0.5-per-cent 
sodium  citrate  in  salt  solution),  gently  tipping  tube  back  and  forth 
between  each  drop. 

2.  Centrifuge  five  minutes. 

799 


800 


APPENDIX  I 


3.  Aspirate  supernatant  citrate  solution  with  suction  curley  pipette 
(Fig.  2),  down  to  leucocyte  zone. 

4.  Fill  tube  three  fourths  full  of  salt  solution ;  mix  by  tipping  tube 
gently  back  and  forth. 

5.  Centrifuge  five  minutes. 

6.  Aspirate  supernatant  salt  solution  do-\\Ti  to  leucocyte  zone. 

7.  Slant  tube  at  angle  of  30°  in  sand  box 

and   pipette   off   the    remaining   salt    solution 
above  the  leucocyte  zone  just  before  using. 


III.  Emulsion: 

1.  Use  residue  from  the  manufacture  of 
Koch's  old  tuberculin  or  growth  on  glycerin 
agar. 

2.  Wash  residue  free  of  glycerin  by  shak- 
ing up  with  a  large  volume  of  salt  solution; 
filter;  dry  residue,  and  powder  in  mortar. 

3.  Grind  powder  in  agate  mortar  one  hour, 
adding  1.5-per-cent  salt  solution  drop  by  drop, 
so  as  to  keep  the  emulsion  at  the  consistency 
of  thin  paste. 

4.  Dilute  with  1.5-per-cent  salt  solution  to 
a  pearl  gray;  centrifuge  one  minute;  dilute 
supernatant  liquid  to  opalescence. 

5.  Determine  strength  of  emulsion  by  "  run- 
ning through  "  and  counting  the  number  of 
bacteria  per  leucocj'te;  if  more  than  1.0  or 
1.2,  dilute  and  reexamine. 

6.  Draw  the  standardized  emulsion  into 
spindle-shaped  capsules  (Fig.  3),  aspirating 
with  rubber  teat  fitted  on  one  end  of  capsule. 
Seal  end  of  capsule,  remove  rubber  teat,  and 
seal  the  other  end  of  capsule. 

7.  Sterilize  by  immersing  capsules  in  boil- 
ing water  for  one  hour. 

8.  When  ready  to  use,  shake  capsule  vigor- 
ously and  break  off  end  with  pinchers  and 
stand  upright  in  sand  box. 


Fig.  2. — Aspirating  Super- 
natant Liquid  with 
Suction  Curley  Pipette 
Down  to  Leucocyte 
Zone  (c).  (From  Surg  , 
Gyn.,  and  Obs.,  Dec, 
1906.) 


TV.  "  EuNNiNG  Through": 

1.  Mark  pipette   (Fig.  4)   with  blue  glass 
pencil   3    em.    from   tip;    fit    rubber    teat    on 


Fig.  3. — Glass  Capsule  Containing  Sterilized  Emulsion  of  Tubercle  Bacilli. 
(From  Surg.,  Gyn.,  and  Obs.,  Oct.,  1907.) 


THE  TUBERCLILO-OPSONIC  INDEX  801 

end    of    pipette    and    compress    teat    slightly    between    thumb    and    first 
finger. 

2.  Aspirate  one  volume  of  cream  (just  touching  tip  of  pipette  to  sur- 
face of  leucocyte  zone),  a  small  column  of  air,  one  volume  of  serum,  a 
small  column  of  air  and  finally  one  volume  of  emulsion. 


:a:D 


Fig.   4. — The  Finished  Pipette,  with  Rubber  Teat  Applied  and  a  Volume 
Marked  off  by  Blue  Pencil  (x).     (From  Surg  ,  Gijn.,  and  Obs  ,  Dec  ,  1906.) 

3.  Mix  the  three  volumes  with  delicate  control  of  rubber  teat  by  press- 
ing out  on  a  slide  each  volume,  raising  pipette  from  slide  to  release  each 
column  of  air,  and  then  finally  drawing  the  mixture  into  the  middle  por- 
tion of  the  capillary  tube  and  sealing  the  tip.  The  rubber  teat  can  then 
be  removed  and  the  pipette  placed  in  the  incubator. 

4.  Prepare  pipettes  in  a  similar  way  from  all  the  patients'  sera  and 
from  the  normal  sera. 

Incubate  fifteen  minutes. 

5.  Break  off  tip  of  pipette  with  fine  file;  mix  contents  by  blowing  them 
in  and  out  once  or  twice  on  glass  slide;  blow  small  drop  on  end  of  clean 
slide. 

6.  Make  film  by  using  smooth  edge  of  a  slide  as  a  spreader  and  draw- 
ing this  spreader,  held  at  an  angle  of  twenty  degrees,  very  gently  over  the 
first  slide.  The  drop  of  mixture  should  be  small  enough  to  allow  the  film 
to  end  on  the  slide  and  not  be  drawn  off  the  slide  by  the  spreader.  The 
film  may  be  made  by  using  cigarette  paper  as  a  spreader  instead  of  a 
glass  slide. 

V.  Staining: 

1.  Fix  film  in  7-per-eent  mercuric  chlorid.  Wash  in  tap  water.  Blot 
in  filter  paper. 

2.  Cover  film  with  carbol  fuchsin  and  bring  to  a  steam.    Wash. 

3.  Decolorize  in  2.5-per-cent  sulphuric  acid  until  very  pale  pink. 
Wash. 

4.  Decolorize  further  in  5-per-cent  acetic  acid  until  film  is  color- 
less.   Wash. 

5.  Counterstain  fifteen  seconds  in  alkaline  methylene-blue.  Wash 
and  blot. 

VI.  Counting: 

1.  Examine  slide  with  low  power  of  microscope.  Select  field  with  leu- 
cocytes abundantly  but  evenly  distributed. 

2.  Examine  selected  field  with  oil  immersion  lens. 

(a)  Avoid  clumps  of  leucocytes — e.  g.,  leucocytes  in  contact. 
(6)  Pass  leucocytes  containing  more  than  8  bacilli, 
(c)  Count  only  the  bacilli  inclosed  within  the  leucocytes. 
52 


802  APPENDIX  I 

(d)  Count  each  fragment  of  bacillus  as  one,  unless  it  is  too  small  to 
be  called  a  bacillus. 

(e)  Count  the  number  of  bacilli  in  50  leucocytes. 

if)  Divide  the  number  of  bacilli  found  in  the  case  of  the  patient's 
serum  by  the  number  found  in  the  case  of  the  normal  serum ;  the  quotient 
is  the  opsonic  index. 

Suggestions  and  Specific  Sources  of  Error 

The  secret  of  a  rapid  collection  of  blood  is  the  making  of  a  quick, 
firm  plunge  of  the  glass  point  into  the  finger,  thus  producing  a  punc- 
ture from  which  blood  flows  freely  and  which  closes  very  quickly,  usually 
at  about  the  coagulation  time  of  blood.  To  obtain  a  firm  blood  clot  and 
a  separation  of  clear  serum,  incubation  of  the  blood  before  centrifuging 
is  helpful.  The  blood  may  be  collected  in  a  fine  U-tube  instead  of  a  cap- 
sule, the  serum  then  separating  in  both  arms  of  the  tube.  The  patient's 
blood  may  be  kept  for  two  or  three  days  in  the  ice  box  before  examining, 
provided  a  normal  blood  is  kept  also  under  the  same  conditions. 

Adequate  washing  of  the  leucocytes  to  remove  all  serum,  careful 
sedimentation  of  the  corpuscular  elements  of  the  blood  so  that  there 
is  a  well-defined  zone  of  leucocytes,  complete  removal  of  all  the  super- 
natant salt  solution  without  disturbance  of  the  corpuscles,  are  impor- 
tant details.  Instead  of  fishing  directly  into  the  leucocyte  layer,  some 
opsonists  aspirate  the  leucocytes  and  upper  layer  of  red  cells  into  a 
second  tube,  mix  thoroughly,  and  fish  from  this  "  leucocyte  emulsion." 
Fewer  leucocytes  per  volume  will  be  fished  from  the  "  leucocyte  emul- 
sion "  than  from  the  leucocyte  layer.  In  my  hands  the  "  leucocyte 
emulsion  "  yields  more  leucocytes  which  are  distorted  and  fragmented 
than  does  the  leucocyte  layer,  due,  I  believe,  to  the  additional  manipula- 
tions of  the  leucocytes  in  preparing  the  "  emulsion." 

The  most  difficult  part  of  the  tuberculo-opsonin  test  is  the  prepara- 
tion of  a  satisfactory  emulsion.  I  have  found  that  an  emulsion  pre- 
pared in  the  above  manner  (Technic  III),  with  a  density  of  about  0.8 
to  1.1  bacillus  per  leucocyte,  will  be  nearly  free  of  clumps,  and  will  have 
a  nicely  countable  distribution  of  bacilli.  Moreover,  enough  can  be  pre- 
pared at  one  time  for  a  month,  thus  giving  one  a  working  emulsion  of 
fixed  strength  for  each  day's  running  through. 

Some  opsonists  use  an  emulsion  of  the  density  of  3  to  4  bacilli  per 
leucocyte.  Clumping  of  the  bacilli  is  more  common  in  such  an  emulsion, 
and  should  the  patient's  serum  opsonize  many  more  bacilli  than  the 
normal  serum,  many  leucocytes  would  be  crowded  with  bacilli  too  numer- 
ous to  count.  If  such  leucocytes  are  passed  by  and  only  those  counted 
which  contain  a  countable  number  of  bacilli,  the  resulting  opsonic  index 
will  not  give  a  fair  idea  of  the  opsonins  in  the  patient's  serum. 


THE  TUBERCULO-OPSONIC  INDEX  803 

Of  the  steps  in  "  running  throngli,"  the  fishing  of  leueoc3-tes  to  get 
a  comparatively  constant  number  on  each  slide  and  the  making  of  uni- 
form smears  are  of  fundamental  importance.  A  disturbing  factor  is  the 
presence  in  some  sera  of  an  unusual  amount  of  agglutinins,  which  cause 
marked  agglutination  of  the  erythrocytes,  and  may  cause  agglutination 
of  the  leucocytes  with  consequent  interference  with  phagocytosis.  The 
use  of  an  autogenous  cream  is  indicated  in  such  cases. 

Carbol  fuchsin  has  long  been  accepted  as  the  best  stain  for  acid-fast 
bacteria,  but  the  fact  that  there  are  strains  of  nonacid-fast  tubercle 
bacilli  has  made  some  opsonists  use  Gram's  stain.  It  is  difficult  to  get 
a  blood  smear  satisfactorily  stained  with  Gram's  stain,  and  it  would 
seem  that  it  possesses  no  superiority  over  carbol  fuchsin  in  the  opsonin 
test,  inasmuch  as  the  same  bacterial  emulsion  is  used  both  for  the  normal 
and  the  patient's  serum  unless  one  assumes  some  specificity  on  the  part 
of  certain  sera  in  opsonizing  nonacid-fast  as  compared  witli  acid-fast 
tubercle  bacilli. 

The  final  step  in  tlic  opsonin  test — e.  g.,  the  examination  of  the 
slides — is  fruitful  of  many  possibilities  of  variations  in  results.  It  is 
absolutely  necessary  to  fix  some  standard  of  counting  such  as  is  given 
in  Technic  VI,  and  to  adhere  consistently  to  it  in  counting  all  the 
slides.  Moreover,  it  is  only  fair  to  the  counter  to  number  the  slides 
so  that  their  identity  is  unknown  to  him. 

There  are  several  ways  of  approacliing  the  subject  of  the  accuracy 
of  the  tuberculo-opsonic  index.  It  has  been  definitely  shown  that  the 
opsonic  index  is  not  a  measure  of  the  real  opsonin  content  of  the  blood. 
It  is  necessary  to  know  within  what  limits  it  is  a  comparative  measure — 
e.  g.,  a  measure  showing  the  relation  between  normal  and  pathological 
opsonins.  The  majority  of  opsonists  test  the  accuracy  by  determining 
the  extreme  limits  of  the  indices  of  normal  individuals,  the  extreme 
limits  of  the  counts  of  tlie  same  slide  by  the  same  and  by  different 
individuals,  and  of  the  counts  of  the  same  serum  "  run  through  "  several 
times.  Kjer-Peterson  believes  that  the  accuracy  of  the  opsonic  indices, 
like  all  observations,  should  be  tested,  not  by  the  mathematical  mean 
or  the  extreme  limits,  but  by  the  mean  error  and  the  law  of  error.  The 
value  of  the  determination  of  the  mean  error  and  the  application  of 
the  law  of  error  would  appear  to  be  found  only  in  a  large  number 
of  observations  made  under  the  same  conditions — for  example,  indices  of 
normal  individuals  and  of  tubercular  cases  before  tuberculin  injections. 
The  majority  of  counters  commonly  find  a  variation  of  0.2  to  0.4,  and  not 
seldom  of  0.6,  in  counting  slides  that  should  theoretically  be  identical 
or  nearly  so.  Such  results  in  themselves  show  the  limitations  of  the 
index,  show  the  impossibility  of  drawing  any  conclusion  from  indices 
wliicli  (lifl'cr  from  out'  another  l)v  loss  tlian  0.1  or  O.n. 


APPENDIX  II 

The  following  leaflet,  by  Dr.  A.  S.  Goodall,  submitted  in  competi- 
tion for  tlie  best  educational  leaflet  for  teachers,  was  awarded  a  gold 
medal  at  the  International  Congress  on  Tuberculosis  of  1908: 

TUBERCULOSIS 

A  Leaflet  for  Teachers 

•  Tuberculosis  is  one  of  the  oldest,  most  common,  and  most  destructive 
diseases.  One  tenth  or  more  of  all  deaths  are  caused  by  it.  It  is  at  the 
same  time  the  most  curable  of  all  serious  diseases.  Its  cause  is  the  tuber- 
cle bacillus,  discovered  by  Professor  Koch  in  1882. 

This  bacillus  is  a  minute  form  of  plant  life,  rod-shaped,  motionless, 
living,  and  able  to  multiply  with  great  rapidity  by  dividing  into  two 
again  and  again.  Outside  the  body  these  bacilli  do  not  multiply.  They 
are  killed  by  direct  sunlight,  fresh  air,  and  other  agencies.  Direct  sun- 
light kills  them  in  a  short  time.  Fresh  air  kills  them  slowly,  in  propor- 
tion to  the  degree  of  light  and  air.  Boiling  for  half  an  hour  will  kill 
the  bacilli,  and  if  sputum  is  in  small  particles  a  shorter  time  will  do. 
Five-per-cent  solution  carbolic  acid  mixed  with  equal  volume  of  sputum 
will  disinfect  in  twenty-four  hours  if  occasionally  stirred.  It  destroys 
bacilli  in  these  smears  of  sputum  quite  quickly.  Intense  cold  does  not 
injure  tubercle  bacilli.  In  a  dark,  damp  room  they  may  live  for  months, 
while  in  a  room  with  open  windows  and  strong  light  they  do  not  live 
many  days. 

Tubercle  bacilli  cannot  be  identified  unless  stained  in  a  cei'tain  way. 
They  look,  through  a  microscope,  like  bits  of  red  silk  thread  or  like 
rows  of  little  red  beads.  They  are  from  ^q^oo  ^o  jow  of  an  inch  long 
and  about  one  fifth  to  one  fourth  as  wide.  Over  16,000,000  could  be  placed 
in  a  single  layer  on  a  two-cent  postage  stamp.  Flies  carry  tubercle  bacilli 
about  if  they  get  at  any  sputum,  and  5,000  bacilli  have  been  found  in  one 
fly  speck.  Tubercle  bacilli  enter  the  body  chiefly  with  dust  in  the  air 
we  breathe,  on  the  food  we  eat,  through  tuberculous  milk  or  meat;  less 
often  by  kissing  and  through  wounds  in  the  skin.  If  breathed  in,  the 
bacilli  may  go  at  once  to  the  lungs  and  cause  disease,  or  they  may  be 
swallowed  with  the  mucus  from  the  throat  and  enter  the  stomach  and 
bowels.  They  may  then,  like  bacilli  taken  in  with  food,  pass  with  the 
products  of  digestion  into  the  circulation,  to  lodge  in  the  lungs  or  else- 
804 


TUBERCULOSIS  805 

where.  They  may  cause  local  disease  of  the  digestive  organs.  The  bacilli 
in  sputum  which  is  swallowed  may  thus  cause  new  centers  of  disease. 
Food  exposed  to  dust  and  flies  or  handled  by  unclean  tuberculous  per- 
sons may  cany  tubercle  bacilli.  Having  entered  the  system,  the  bacilli 
may  be  destroyed  if  the  person  is  healthy,  they  may  multiply  and  cause 
tuberculosis,  or  they  may  lie  dormant  for  long  periods  until  the  person's 
physical  condition  becomes  suitable  for  their  growth. 

The  tubercle  bacillus  found  in  man  and  that  found  in  cattle  and  other 
animals  are  the  same  for  all  practical  purposes,  although  differing  in 
minor  details.  Tubercle  bacilli  from  one  creature  may  produce  tuber- 
culosis in  any  other  creature. 

Tuberculosis  is  communicable  like  typhoid  fever,  but  not  infectious 
like  scarlet  fever.  The  bacilli  are  thrown  out  of  the  body  in  the  dis- 
charges coming  from  the  diseased  regions,  the  pus  from  glands  or  bones, 
the  sputum  from  the  lungs  or  throat.  Sputum  contains  great  numbers 
of  bacilli;  the  pus  not  so  many.  Sputum  carelessly  scattered  by  tuber- 
culous people  causes  the  vast  majority  of  cases  of  tuberculosis.  Tuber- 
culous milk  and  meat  cause  a  small  portion,  and  should  be  guarded 
against  by  maintaining  and  extending  the  official  inspection  of  milk  and 
meat. 

The  germs  from  consumptives  are  carried  by  the  sputum,  not  by 
the  breath.  The  breath  itself  is  harmless.  If  sputum  be  carelessly 
allowed  to  scatter,  it  dries,  becomes  powdered  and  mingled  with  dust, 
and  the  bacilli  are  then  inhaled  by  some  one,  or  they  settle  on  the  food, 
and  thus  enter  the  digestive  tract.  If  one  expectorates  upon  the  side- 
walk or  in  a  car,  some  one  carries  part  of  the  sputum  on  his  shoes  or 
clothes  into  the  house,  where  it  will  be  inhaled.  Dry  sputum  flies  about 
and  is  very  dangerous.  Wet  sputum  clings  where  it  lies,  and  is  not  as 
dangerous.  Wet  sputum  in  a  cup  is  perfectly  safe,  so  long  as  it  is  not 
spilled  and  is  protected  from  the  flies.  The  person  who  uses  a  sputum 
box  is  safe;  the  one  who  spits  on  the  floor  is  dangerous,  and  should  be 
ostracized.  Putting  pins,  pencils,  hairpins,  or  fingers  into  the  mouth  is 
liable  to  scatter  bacilli  about.  It  is  dangerous  to  swap  gum,  or  to  eat 
apples,  etc.,  that  another  has  bitten. 

In  rare  cases  actual  tuberculosis  may  be  directly  inherited.  As  in- 
ability to  resist  this  disease,  a  predisposition  may  be  inherited  from 
parents  who  have  tuberculosis,  of  who  from  any  cause  are  weak  or 
unhealtbj'.  Generally,  however,  the  extension  of  tuberculosis  throughout 
a  family  is  due  to  the  transfer  of  bacilli  from  one  member  to  another 
through  improper  care  of  the  sputum. 

Any  form  of  sickness  or  bad  living  which  weakens  one's  power  of 
resistance  renders  one  liable  to  tuberculosis.  Overwork,  poor  food,  lack 
of  fresh  air,  drinking,  excessive  use  of  tobacco,  vicious  habits,  late  hours, 
and  inherited  weak  constitution  or  unsoundness,  all  predispose.  Poverty 
is  the  greatest  predisposing  cause,  for  the  poor  must  contend  against 
hard  work,  long  hours,  poor  and  often  insufficient  food,  and  overcrowded, 
unsanitary,  poorly  ventilated  quarters. 


806  APPENDIX  II 

No  age  is  exempt,  but  tuberculosis  is  most  common  in  adult  life. 

If  the  tuberculous  discharges  from  a  patient  are  properly  collected 
and  destroyed  no  danger  results,  and  the  patient  is  not  a  menace  to 
nurse,  neighbor,  or  fellow-workman.  Discharges  from  glands,  bones,  etc., 
must  be  caught  on  copious  dressing.  These  dressings  should  be  wet  before 
changing,  to  prevent  any  dry  discharge  from  scaling  off,  and  should  be 
immediately  burned.  All  sputum  should  be  deposited  in  small  burnable, 
waterproof  paper  boxes,  carried  about  in  a  metal  frame.  The  paper 
lining  is  to  be  renewed  as  often  as  necessary,  at  least  once  a  day,  and 
burned  with  its  contents.  It  may  be  necessary  to  put  some  sawdust  in 
a  box  to  mix  with  the  sputum,  so  that  the  latter  may  not  run  through 
the  fire  into  the  ashes.  The  metal  container  should  be  boiled,  or  soaked 
in  five-per-cent  carbolic  solution.  A  pocket  box  of  the  above  paper 
may  be  used,  but  does  not  hold  much,  and  is  not  adequate  if  one  raises 
freely.  Both  boxes  are  made  by  Seabury  &  Johnson,  New  York  City, 
and  the  Aseptic  Drinking  Cup  Company,  Cambridge,  Mass.  If  these 
cannot  be  afforded,  a  tin  cup,  part  full  of  water,  will  answer,  but  the 
cup  with  its  contents  must  be  boiled  vigorously  for  half  an  hour  before 
it  is  emptied,  and  it  must  be  covered  while  boiling,  as  otherwise  some 
germs  on  the  surface  may  remain  alive.  Metal  pocket  boxes  may  be 
used,  but  should  be  boiled.  Sputum  must  never  be  put  where  it  can  dry 
and  fly  away,  as  by  expectorating  into  a  cloth  or  handkerchief.  Never- 
theless, a  cloth  should  always  be  held  over  the  mouth  when  coughing, 
to  catch  the  fine  spray  that  flies,  and  this  cloth  should  be  burned  and  a 
new  one  taken  frequently. 

Do  not  allow  children  in  the  sleeping  room  of  a  consumptive.  In 
a  consumptive's  room  use  small  rugs  instead  of  carpets,  sweep  only  with 
a  broom  bag  dampened  with  five-per-cent  carbolic  solution,  and  dust 
with  a  cloth  similarly  dampened.  Wash  and  boil  both  broom  bag  and 
duster  frequently.  Boil  the  bed  linen.  Use  paper  napkins  at  the  table 
and  gauze  for  handkerchiefs,  and  burn  both.  Knives,  forks,  spoons,  etc., 
should  be  kept  separate  and  well  washed  and  scalded. 

In  the  lungs  the  bacilli  grow  in  the  partitions  between  the  air  cells 
and  passages,  and  as  long  as  the  membrane  lining  these  spaces  is  intact 
no  bacilli  can  get  into  the  spaces  and  none  can  be  found  in  the  sputum, 
although  the  patient  may  be  quite  ill.  It  is  dangerous  to  wait  until 
bacilli  are  found  before  admitting  that  one  has  tuberculosis.  The  diag- 
nosis can  frequently  be  made  upon  other  evidence  before  bacilli  are  found. 
The  chance  of  cure  is  smaller  after  bacilli  appear  in  the  sputum.  The 
bacilli  do  harm  by  destroying  tissue  and  by  poisoning  the  general  system 
with  soluble  poisons.  If  recovery  takes  place  the  injured  tissue  is  replaced 
hy  scarlike  tissue. 

The  early  symptoms  of  tuberculosis  are  slight  cough,  with  or  without 
expectoration,  hoarseness,  rapid  pulse,  slight  fever  (99.5°  F.,  if  occurring 
frequently,  is  suspicious),  loss  of  weight  and  strength,  and  gastric  dis- 
turbance. Any  of  these,  if  persistent,  or  recurrent,  calls  for  prompt  ex- 
amination of  the  lungs  and  sputum  by  an  expert.     Later  on  come  night 


TUBERCULOSIS  807 

sweats,  the  hectic  flush,  and  shortness  of  breath.  Hemorrhage,  pain  in 
the  chest,  and  cessation  of  menstruation  may  be  early  or  late  symptoms. 
Pleurisy  generally  means  tuberculosis.  Bacilli  in  the  sputum  constitute 
a  positive  proof.  Their  absence  proves  nothing.  As  the  lungs  extend 
to  the  sixth  rib  in  front  and  the  tenth  rib  behind,  the  clothes  must  be 
entirely  removed  to  the  waist,  to  allow  complete  and  thorough  exami- 
nation. 

No  medicine  has  any  effect  upon  the  tubercle  bacilli  inside  the  body; 
nevertheless,  consult  your  physician,  for  he  can  guide  you  safely  past 
many  pitfalls.  Alcoholic  remedies  are  injurious.  Any  medicine  that 
disturbs  digestion  is  injurious. 

Fresh  air,  rest,  and  good  food  put  the  body  in  condition  to  overcome 
the  bacilli.  This  is  the  treatment  of  to-day.  Kest  means  absence  of  work, 
to  sit  or  lie  all  day  in  the  open  air  (in  the  yard,  on  the  porch,  or  on  the 
roof),  to  read,  to  sleep,  to  spend  eight  or  ten  hours  nightly  in  bed. 

Fresh  air  means  to  spend  all  day  out  of  doors,  and  thus  resting,  not 
exercising.  Eest  has  never  hurt  a  consumptive ;  overexercise  has  killed 
thousands.  Be  out  of  doors,  but  be  protected  from  storms  and  from 
wind.  Sleep  outdoors  or  with  windows  open  both  top  and  bottom.  Oc- 
cupy a  room  with  windows  on  two  sides  if  possible.  On  winter  nights 
wear  underclothing,  stockings,  a  cap  or  hood,  a  cotton-flannel  nightgown, 
and  sleep  beneath  cotton-flannel  sheets.  Keep  comfortable,  but  have  the 
air.  At  night  there  is  no  air  other  than  night  air,  and  the  fresh  outdoor 
night  air  is  infinitely  better  than  the  stale  indoor  night  air. 

Food  should  be  abundant,  varied,  nourishing,  well  cooked,  and  at- 
tractively served.  Milk,  eggs,  meat,  bread  and  butter,  cereals,  fruits, 
vegetables — but  little  pastry  or  sweets.  Do  not  stuff;  eat  as  much  as 
your  stomach  can  manage,  but  do  not  overwork  it.  All  this  treatment 
one  may  have  at  home,  and  the  home  treatment  is  all  that  most  patients 
can  get.     For  many  it  suffices. 

Eemoval  to  a  suitable  climate  combined  with  this  treatment  gives  one 
a  better  chance  than  treatment  at  home.  Treatment  at  a  sanatorium 
shows  better  results  than  treatment  at  a  hotel  or  cottage  in  the  same 
region.  However,  comfort  and  plenty  at  home  are  better  than  discom- 
fort and  want  in  the  best  climate.  Climate  alone  will  not  effect  a  cure 
nor  enable  one  to  work.  Like  food  and  rest,  climate  is  desirable,  but  the 
two  former  are  to  be  chosen  if  one  cannot  afford  all  three. 

A  cold  sponge  or  shower  bath,  taken  in  a  comfortable  room  daily, 
makes  the  skin  perform  its  functions  better,  accustoms  it  to  sudden 
changes  of  temperature,  and  renders  one  less  susceptible  to  colds.  If 
the  reaction  is  not  prompt  and  complete,  the  bath  should  be  less  cold 
until  tolerance  is  acquired. 

A  person  who  has  had  or  is  likely  to  have  tuberculosis  should  choose 
an  occupation  demanding  as  little  heavy  physical  labor,  anxiety,  or 
wearing  responsibility  as  possible,  and  affording  the  shortest  hours,  the 
most  outdoor  life,  or  the  best  ventilation  inside,  with  sufficient  remuner- 
ation to  provide  sanitary  quarters  and  plenty  of  good  food. 


APPENDIX   III 

The  following  leaflet,  by  Dr.  George  H.  Kress,  of  Los  Angeles,  Cal., 
submitted  in  competition  for  the  best  educational  leaflet  for  mothers, 
was  awarded  a  gold  medal  at  the  International  Congress  on  Tuberculosis 
in  1908: 

FACTS  A  MOTHER  SHOULD  KNOW  CONCERNING 
TUBERCULOSIS 

Titherculosis  a  Disease  Responsible  for  Untold  Sorrow  to  Mothers. 

Tuberculosis,  or  consumption,  is  a  disease  which  robs  the  mothers  of 
the  world  of  one  out  of  every  ten  children. 

The  causes  of  this  disease  are  known,  likewise  the  means  whereby  it 
may  be  prevented. 

Every  mother  owes  it  to  herself  and  her  family  to  know  about  tuber- 
culosis, so  that  the  lives  of  her  children  may  not  be  placed  in  peril. 

The  Frequency  of  Tuberculosis. 

In  the  United  States  more  than  150,000  persons  die  every  year  from 
tuberculosis.  The  great  majority  of  these  persons  are  iu  the  prime  of 
life.  Many  of  these  persons  are  married,  and  their  untimely  deaths  mean 
dependent  families  to  be  cared  for  by  the  State. 

The  loss  in  money  to  the  United  States  from  these  preventable  deaths 
every  year  amounts  to  more  than  three  hundred  million  dollars.  The 
suffering  caused  by  the  disease  it  is  impossible  to  estimate. 

Two  Important  Facts  ahoiit  Tuberculosis. 

Tuberculosis  is  preventable. 

Tuberculosis  is  curable. 

These  are  most  important  facts  worthy  of  widest  circulation,  especially 
since  contrary  ideas  prevail. 

Universal  prevention  and  cure  of  this  disease  will  result  only  when 
there  is  universal  effort  against  it. 

In  this  work  of  prevention  and  cure,  the  mothers  of  the  world  can 
wield  a  tremendous  influence. 

The  world  counts  on  the  aid  of  the  mothers,  for  what  mother  would 
condemn  either  her  own  or  any  other  child  to  an  unnecessary  death  ? 
808 


FACTS  A  :\IOTHER  SHOULD  KNOW  CONCERNING  TUBERCULOSIS  809 

What  are  the  Causes  of  Tuberculosis? 

First,  there  is  an  exciting  cause,  which  is  a  very  small  plant  called 
a  germ.  There  can  be  no  tuberculosis  unless  this  germ  be  present  in 
the  body. 

Second,  the  person  who  takes  this  disease  has  a  body  that  is  favorable 
to  it.  Any  person  whose  health  and  strength  is  run  down  is  predisposed 
to  tuberculosis,  because  in  such  a  person  there  is  not  much  resistance. 

The  two  things  necessaiy,  then,  for  tuberculosis  are  the  presence  of  a 
certain  germ  in  the  body  of  a  person  whose  health,  for  any  reason,  has 
been  run   down. 

What   the  Germ  Does   in  the  Lungs. 

When  the  germ  gets  into  the  body  of  a  person  who  is  run  down  in 
health,  it  finds  a  soil  suitable  for  its  growth  and  produces  the  disease 
called  tuberculosis. 

The  germs  produce  little  granules  called  tubercles,  which  may  later 
become  little  ulcers  or  abscesses. 

Poisons  are  also  thrown  out  by  the  germs  and  get  into  the  blood,  and 
these  poisons  cause  most  of  the  symptoms  of  the  disease. 

W^hat  are  the  Symptoms  of  Tuherculosis? 

The  symptoms  are  different,  according  to  the  stage. 

It  is  the  symptoms  of  the  early  stages  that  should  be  learned,  for  it 
is  then  that  cure  can  be  brought  about  and  lives  saved.  What  are  these 
symptoms  ? 

The  disease  usually  comes  on  in  very  slow  and  mild  fashion.  That  is 
what  throws  the  persons  infected  off  their  guard.  There  may  be  nothing 
more  than  a  tired  feeling,  especially  after  work,  a  lessened  appetite,  some 
loss  of  weight,  and  perhaps  an  occasional  cough. 

As  the  disease  grows  w^orse,  these  symptoms  do  likewise.  The  loss  of 
weight  may  be  very  noticeable ;  there  may  be  fever  and  night  sweats.  With 
the  more  frequent  cough  much  sputum  may  be  expectorated. 

In  the  far  advanced  stages  some  of  these  symptoms — like  cough,  loss 
of  weight,  and  fever — may  be  very  pronounced.  Then  we  have  the  picture 
of  the  "  consumjjtive." 

How  May  Tuherculosis  he  Prevented? 

Tuberculosis  is  prevented  by  doing  two  things : 

L   Killing   the  germs   that   cause  the  disease. 

2.  Having  people  become  healthy,  so  that  they  will  not  be  predisposed 
to  the  disease. 

How  are  the  Germs  to  he  Destroyed? 

The  germs  are  scattered  far  and  wide  in  the  sputum  which  is  coughed 
up   by   consumptives.      One   consumptive  can   cough   up   in   a   single   day 
several  billion  of  these  germs. 
53 


810  APPENDIX   III 

When  this  sputum  dries  as  dust  the  germs  are  blown  about  in  all 
directions,  to  get  into  the  air  we  breathe  and  on  the  food  and  things 
we  eat  and  handle.  In  this  way  every  person  at  some  time  in  life  probably 
gets  the  germs  into  his  body. 

To  destroy  these  germs,  all  that  is  necessary  is  to  destroy  the  sputum. 

If  sputum  be  coughed  into  paper  cups  or  napkins,  these  can  be  burned 
and  the  germs  destroyed.  For  spittoons,  disinfectant  solutions  like  lye 
should  be  used. 

Coughing  in  people's  faces  or  spitting  on  the  streets,  and  especially 
on  floors,  is  dangerous. 

How  May  the  Predisposition  of  a  Weakened  Body  he  Overcome? 

Bodily  weakness — that  is,  the  predisposition  to  tuberculosis — may  be 
overcome  by  right  living,  particularly  by  breathing  pure  air,  eating  nour- 
ishing food,  and  getting  the  proper  proportion  of  rest  and  exercise. 

A  child  weak  at  birth  should  be  guarded,  and  as  it  grows  older  made 
to  spend  much  time  out  of  doors. 

Children  weak  from  disease  like  measles  or  whooping  cough  should 
not  be  neglected.  These  and  kindred  diseases  are  often  responsible  for 
tuberculosis  being  set  up  later  on  in  life. 

Children  should  not  be  made  to  work  at  too  early  an  age,  nor  allowed 
to  study  so  hard  as  to  interfere  with  health. 

The  food  should  be  eaten  slowly,  and  should  always  be  nourishing. 
If  cow's  milk  is  iised,  it  should  be  obtained,  if  possible,  from  a  dairy 
having  no  tubercuhnis  cattle. 

The  living  and  sleeping  rooms  of  the  family  should  always  be  well 
ventilated.  The  hiunan  body,  if  it  is  to  be  in  a  healthy  state,  must  have 
pure  air.  Bedrooms  should  not  be  overcrowded  and  single  beds  are  ad- 
visable. 

The  above  rules  can  be  taken  to  heart  by  grown-up  persons  as  well. 

These  simple  rules  are  worth  observing,  because  a  healthy  body  is  usu- 
ally able  to  overcome  tuberculosis,  but  a  weakened  body  is  not. 

How  May  Tuhercidosis  he  Cured? 

Tuberculosis  may  be  cured  by  the  same  measures  which  prevent  it, 
namely,  by  making  the  body  stronger  so  that  it  will  be  able  to  kill  the 
germs  that  have  gotten  into  the  tissues. 

The  pure  air,  good  food,  lots  of  rest  treatment,  cures  more  people  of 
tuberculosis  than  all  the  medicines  that  are  known. 

Avoid  patent  medicines  for  tuberculosis,  particularly  cough  medicines, 
as  these  usually  contain  alcohol  and  opiates,  which,  though  they  may 
make  the  patient  feel  better,  usually  allow  the  disease  to  grow  worse. 

The  above  methods  should  be  carried  out  under  the  advice  of  a  private 
or  dispensary  physician  who  has  made  a  study  of  the  disease. 

"  Develop  healthy  bodies." 


APPENDIX   IV 

AN"  ACT  to  provide  for  reports  and  registration  of  all  cases  of  tuber- 
culosis  in  ,   for  the  free  examination  of  sputum   in   suspected 

cases,  and  for  preventing  the  spread  of  tuberculosis  in  : 

Be  it  Enacted,  etc.  That  tuberculosis  is  hereby  declared  to  be  an 
infectious    and   communicable    disease,   dangerous   to    the   public   health. 

It  shall  be  the  duty  of  every  physician  in  to  report  to  the  health 

officer    of    said    ,    in    writing,    on   forms    to   be    provided    by    said 

officer,  the  name,  age,  sex,  color,  occupation,  and  address  of  every  per- 
son in  said  having  pulmonary  or  any  other  communicable  form 

of  tuberculosis,  who  has  been  attended  by  such  physician  for  the  first 
time,  within  one  week  after  the  disease  is  recognized.  It  shall  also  be  the 
duty  of  the  chief  officer  having  charge  for  the  time  being  of  each  and 
every   hospital,   dispensary,   asylum,   or   other   similar   public   or   private 

institutions    in    said    to    report    in    like    manner    the    name,    age, 

sex,  color,  occupation,  and  last  address  of  every  patient  afflicted  with 
pulmonary  or  any  other  communicable  form  of  tuberculosis  who  is  in 
his  care  or  who  has  come  under  his  observation,  within  one  week  of  such 
time. 

Section    2. — That    the    health   officer    of   said    shall    make,    or 

cause  to  be  made,  a  microscopical  examination  of  the  sputum  of  persons 
having  symptoms  of  tubercidosis,  which  shall  be  accompanied  by  a  blank 
giving  name,  age,  sex,  color,  occupation,  and  address  of  the  patient  when- 
ever it  be  requested  by  the  attending  physician  or  by  the  proper  officer 
of  any  hospital  or  dispensary;  and  shall  promptly  make  a  report  thereof, 
free  of  charge,  to  the  physician  or  officer  upon  whose  application  the 
examination  was  made. 

Sec.  3. — That  the  health  officer  of  said —  shall  cause  all  reports 

made  in  accordance  with  the  first  section,  and  all  reports  showing  the 
presence  of  tubercle  bacilli  received  in  accordance  with  the  second  section 
of  this  act  to  be  recorded  in  a  register,  of  which  he  shall  be  the  custodian, 
and  which  shall  not  be  open  to  inspection  by  anyone  outside  the  health 

department    of   said  ;   and   neither   said  health  officer  nor   anyone 

connected  with  said  health  department  shall  permit  any  such  report  or 
record  to  be  divulged  in  such  manner  as  to  disclose  the  identity  of  the 
person  to  whom  it  relates,  except  as  it  may  be  necessary  in  carrying  out 
the  provisions  of  this  act. 

Sec.  4. — That  in  case  the  attending  phyt^ician  fails  to  request  in  his 
report  that  they  shall  not  be  furnished,  it  shall  be  the  duty  of  the  health 

811 


812  APPENDIX  IV 

department  to  supply  to  each  patient,  or  to  those  in  charge  of  such 
patients,  printed  instructions  as  to  the  methods  to  be  employed  to  pre- 
vent the  spread  of  the  disease  in  each  case  of  tuberculosis  so  reported. 

Sec.  5. — That  in  case  of  the  vacation  of  any  apartments  or  premises 
by  death  from  pulmonar3^  or  any  other  communicable  form  of  tubercu- 
losis, or  by  the  removal  therefrom  of  a  person  or  persons  so  afflicted, 
it  shall  be  the  duty  of  the  attending  physician,  or,  if  there  be  no  such 
phj-sician,  or  if  such  physician  be  absent,  of  the  owner,  lessee,  tenant, 
occupant,  or  other  person  in  charge  of  said  apartments,  or  premises, 
to  notify  the  health  officer,  in  writing,  of  such  death  or  removal, 
within  twenty-four  hours  thereafter,  and  such  apartments  or  premises 
shall  then  be  disinfected  by  the  health  department  at  public  expense,  or, 
if  the  owner  prefers,  by  the  owner  to  the  satisfaction  of  the  health 
department,  and  shall  not  again  be  occupied  until  so  disinfected. 

Sec.  6. — That  it  shall  be  the  duty  of  every  person  in  attendance  upon 
anyone  afflicted  therewith,  and  of  the  authorities  of  public  and  private 

institutions   or   dispensaries   in  said   ,   to   observe   and   enforce   all 

sanitary  rules  and  regulations  of  the  health  department  for  preventing 
the  spread  of  tuberculosis. 

Sec.  7. — That  upon  the  recoveiy  of  any  patient  from  the  tubercu- 
lous condition  for  which  he  was  previously  reported  a  report  to  that 
effect  to  the  health  department,  made  by  the  attending  physician,  shall 
be  recorded  and  shall  relieve  said  patient  from  further  liability  to  any 
requirements  imposed  by  this  act. 

Sec.  8. — That  any  person  violating  any  of  the  provisions  of  this  act 
shall,  upon  conviction  thereof,  be  deemed  guilty  of  a  misdemeanor,  and 
shall  be  punished  by  a  fine  not  exceeding  twenty-five  dollars. 

Sec.  9. — That  all  acts  and  parts  of  acts  contrary  to  the  provisions  of 
this  act,  or  inconsistent  therewith,  be,  and  the  same  are,  hereby  repealed. 


APPENDIX  V 

INSTEUCTIOXS  FOR  THE  PHYSICIAN'S  USE  IN  PRIVATE 

PRACTICE 

COMPILED   BY  S.   A.   KNOPF,   M.D. 

The  leaflet  wliicli  is  presented  here  I  have  made  use  of  in  my  pri- 
vate and  consultation  practice,  and  also  in  my  hosjiital  and  dispensary 
work,  for  a  number  of  years.  Reading  it  to  the  patient  has  helped  me 
to  impress  upon  liim  vital  points  in  the  prevention  and  treatment  of  the 
disease,  some  of  which,  had  I  relied  on  my  memory,  I  am  quite  sure 
would  often  have  been  forgotten. 

Except  in  hospital  or  dispensary  practice,  I  do  not  recommend  giving 
•these  instructions  to  a  patient  in  printed  form.  To  have  them  type- 
written will  make  them  seem  more  as  if  intended  for  liim  individually, 
even  though  the  special  directions  may  be  filled  out  in  writing.  The 
instructions  should  always  be  signed  by  the  attending  physician. 

General  Advice 

Be  hopeful  and  cheerful,  for  your  disease  can  be  cured.^ 

Avoid  anxieties  and  worry  as  far  as  possible. 

Do  not  talk  to  anyone  about  your  disease  or  symptoms,  except  to  your 
physician  or  nurse. 

When  indoors  remain  in  the  svmniest  and  best-ventilated  room.  It  is 
better  to  have  no  carpets  or  heavy  hangings  in  the  room ;  small  rugs 
and  washable  curtains  may  be  allowed.  Cleaning  should  be  done 
with  a  moist  or  slightly  oily  rag,  according  to  the  surface  to  be 
gone  over. 

Never  sleep  or  stay  in  a  hot  room.  Have  your  own  sleeping  room  if 
possible,  but  always  have  your  own  bed,  which  should  be  freely  aired 
during  the  daytime.  In  cold  weather  you  may  have  a  fire  in  the 
room,  but  keep  the  window  wide  enough  open  not  to  have  the  room 
warmer  than  60°  to  65°  F. 

Keep  at  least  one  window  always  open  in  your  bedroom.  Night  air  is 
as  good,  and  in  cities  even  better,  than  day  air. 

'  If  the  condition  of  the  patient  demands  that  it  would  be  more  advisable  to 
say  "your  condition  can  be  improved,"  this  should  of  course  be  done. 

813 


814  APPENDIX   V 

Have  at  least  nine  hours'  sleep  in  the  twenty-four,  and  retire  early.  If 
you  have  to  work  during  the  week,  and  feel  as  if  you  do  not  get 
a  sufficient  amount  of  rest,  remain  in  bed  all  Sunday  morning  and 
get  thoroughly  rested. 

If  you  are  directed  to  sleep  outdoors  in  a  tent,  on  a  veranda,  on  a  porch, 
or  in  a  window-tent,  begin  gradually,  and  in  cold  weather  be  par- 
ticular to  dress  warmly  for  the  night  and  have  plenty  of  bed  covering. 
Your  feet  must  be  kept  warm. 

Remain  in  the  sunshine  as  much  as  possible,  except  in  very  hot  weather; 
but  always  protect  your  head.  If  there  is  no  sheltered  spot  out- 
doors or  on  a  veranda,  the  best  place  to  take  a  sun  bath  is  in  front 
of  the  open  window.  Extend  yourself  on  a  comfortable  lounge  with 
your  head  in  the  shade  and  the  body  bathed  by  the  rays  of  the  sun; 
remain  there  as  long  as  you  feel  comfortable. 

A  feeling  of  discomfort,  headache,  or  a  rise  of  temperature,  are  indi- 
cations that  you  have  been  exposed  too  much  to  the  sun,  and  that 
you  must  seek  the  advice  of  the  physician  before  resuming  the  sun- 
baths. 

Live  as  much  as  you  can  in  the  open  air.  Do  not  be  afraid  of  cold 
weather;  in  snowy  or  rainy  weather  always  w'ear  rubber  shoes  and 
an  outer  garment  which  will  keep  you  dry  and  warm.  Remain  in- 
doors only  on  very  windy  and  stormy  days. 

The  rest  cure  in  the  open  air  on  a  reclining  chair  can  and  should  be 
taken  in  all  kinds  of  weathei',  providing  you  protect  yourself  against 
rain  or  too  strong  winds.  Whether  you  are  taking  your  rest  cure 
outdoors  during  the  day,  are  sleeping  outdoors,  in  a  window-tent,  or 
in  a  room  with  the  windows  wide  open,  if  you  suffer  from  the  cold, 
it  is  time  to  return  to  the  house  or  close  part  of  the  window.  Pro- 
tect yourself  better  the  next  time,  for  the  air  does  not  do  you  any 
good  when  you  become  chilled. 

Dress  yourself  comfortably,  but  not  so  heavily  as  to  hinder  your  move- 
ments. Discard  chest  protectors,  for  they  only  tend  to  make  you 
take  colds  more  easily.  Wear  a  suit  of  linen-mesh  underwear;  but 
do  not  change  from  wool  to  linen  in  cold  weather  unless  you  begin 
by  wearing  the  linen  mesh  next  the  skin  and  some  wamier  undergar- 
ment of  cotton  or  wool  over  it.  Keep  your  feet  dry  and  warm, 
particularly  when  you  are  taking  the  rest  cure  in  the  open  air 
in  cold  weather.  Use  a  heated  soapstone  or  hot-water  bag,  if 
necessary. 

Take  a  bodily  and  mental  rest  on  a  comfortable  reclining  chair  for  about 
thirty  minutes  before  and  after  the  principal  meals. 

Do  not  take  any  kind  of  medicine  (patent  or  other)  or  exercise,  except 
such  as  are  prescribed  by  your  physician. 

Avoid  all  unnecessary  exertions,  mental  or  physical.  Avoid  exciting 
conversation.  Never  run  nor  lift  heavy  weights.  Never  take  any 
exercise  when  you  are  tired,  nor  exercise  to  the  extent  of  getting 
tired.     Avoid  getting  into  perspiration. 


INSTRUCTIONS  FOR   PHYSICIAN'S   USE   IX   PRIVATE   PRACTICE    815 

When  Avalking  against  the  wind,  riding  in  carriage  or  automobile,  do 
not  converse,  but  keep  your  mouth  closed,  and  breathe  through  the 
nose  only. 

Take  your  walking  exercises  as  you  have  been  directed,  and,  when 
feasible,  begin  with  walking  slowly  uphill ;  the  return  will  then  be 
easier. 

Take  your  breathing  exercises  regularly  as  prescribed;  always  breathe 
through  the  nose. 

Avoid  strong  draughts,  dust,  and  dampness,  and  all  places  where  the  air 
is  bad,  such  as  theaters,  concert  halls,  crowded  meeting  places,  etc. 

In  cold  weather  bathe  and  dress  in  a  warm  room.  If  you  sleep  in  a  tent, 
have  a  fire  made  before  rising;  if  on  a  veranda,  have  your  bed  rolled 
into  a  warm  room  or  go  there  quickly,  covering  yourself  with  a  coat 
or  blanket.  If  you  sleep  in  a  window-tent,  close  the  window,  and 
wait  until  the  room  is  sufficiently  warm  before  dressing.  As  a  rule, 
in  winter  do  not  leave  the  house  until  an  hour  after  sunrise,  because 
the  air  before  that  time  is  usually  very  much  colder.  By  taking  these 
precautions  you  will  avoid  being  chilled. 

Try  to  control  your  cough.  You  should  train  yourself  to  cough  only 
when  you  have  to  expectorate. 

All  expectoration — that  is  to  say,  spittle — contains  germs.  Some  of  these, 
especially  when  there  is  throat,  bronchial,  or  lung  trouble,  are  dan- 
gerous. Thus  it  is  best  to  be  careful  and  gather  all  the  expectora- 
tion, of  whatever  nature,  and  destroy  it  before  harm  can  be  done 
by  it.  To  this  end  one  should  always  expectorate  in  a  proper  recep- 
tacle, and  see  to  it  that  its  contents  are  destroyed.  Carelessness  in 
this  respect  is  sure  to  cause  the  spread  of  the  disease  to  others.  This 
method  of  disposing  of  the  sputum  also  protects  the  patient  himself 
from  taking  the  same  germs  into  his  system  again,  either  by  inhaling 
dust  containing  particles  of  the  dried  sputum,  or  by  infecting  him- 
self through  sores.  Be  particularly  careful  w^hen  you  have  any 
wound  or  scratch  on  your  hands,  for  if  tuberculous  matter  comes 
in  contact  with  an  open  wound,  local  infection  or  inoculation  may 
take  place.  It  is  not  safe  to  use  a  handkerchief  to  spit  into,  since 
in  this  way  an  infection  of  the  nose  is  possible. 

When  at  home  always  expectorate  in  a  spittoon  filled  partially  with 
water,  or,  better,  with  water  into  which  you  have  put  one  part  of 
carbolic  acid  to  twenty  parts  of  water  (five-per-cent  solution).  When 
you  cannot  conveniently  get  at  the  stationary  cuspidor,  use  a  pocket 
spittoon.  When  away  from  home  or  if  the  use  of  such  a  pocket 
flask  or  spittoon  is  not  practicable,  use  squares  of  muslin  simulating 
handkerchiefs  or  use  Japanese  paper  handkerchiefs  to  expectorate 
in.  Keep  them  in  a  leather  pouch  or  in  a  pocket  lined  with  imper- 
meable material  until  you  can  burn  them  on  your  return  home. 
Ladies  should  divide  their  handbags  into  two  compartments  to  serve 
the  same  purpose.  For  people  who  live  in  flats  where  the  cooking  is 
done  over  gas,  it  may  be  difficult  to  find  a  place  to  burn  the  cheap 


816  APPENDIX  V 

handkerchiefs,  rags,  pasteboard  pocket  spittoons,  or  paper.  While  the 
thin  paper  might  be  thrown  into  the  water-closet,  this  cannot  be  done 
with  rags  or  pasteboard.  Individuals  thus  situated  should  use  thin 
paper  which  they  can  throw  into  the  water-closet,  or  a  pocket  flask 
of  metal  or  glass  which  should  be  emptied  into  the  closet  and  cleaned 
with  hot  water.  There  are  small  and  convenient  ones  that  can  be 
hidden  in  the  folds  of  a  handkerchief  when  used. 

All  stationary  spittoons  should  be  covered,  for  flies  and  other  insects  may 
crawl  over  them,  partake  of  the  tuberculous  matter,  and  by  depos- 
iting the  latter  on  articles  of  food  or  elsewhere,  become  propagators 
of  tuberculosis. 

Whether  sick  or  well,  never  expectorate  on  the  sidewalk,  but  always  in  the 
gutter  if  there  is  no  spittoon  convenient. 

Never  swallow  your  expectoration.  Never  use  the  same  handkerchief  to 
wipe  your  nose  which  you  use  to  wipe  your  mouth  after  having 
expectorated.  Always  cover  your  mouth  with  a  handkerchief  or  the 
hand  while  coughing  or  sneezing.  Never  kiss  anyone  on  the  mouth 
nor  allow  it  to  be  done  to  you. 

Handle  the  soiled  personal  and  bed  linen,  especially  handkerchiefs,  as 
little  as  possible  in  the  dry  state.  When  soiled,  place  these  articles 
in  water  until  ready  to  be  washed. 

It  is  best  not  to  wear  any  mustache  or  beard,  but  if  worn,  they  should  be 
closely  clipped. 

Always  wash  your  hands  thoroughly  before  touching  food. 


Directions  Concerning  Food,  Drink,  Stimulants,  Etc. 

Live  on  a  mixed  diet — that  is  to  say,  meat,  fish,  oj'sters,  vegetables  (espe- 
cially spinach,  lentils,  cauliflower)  ;  fresh  and  cooked  fruit,  particu- 
larly grapes,  plenty  of  fresh  milk,  fresh  eggs;  all  sorts  of  easily 
digested  fats,  especially  butter.  Thick,  nourishing  soups  should  be 
eaten  with  the  principal  meals.  Raw,  chopped,  or  scraped  beef  is 
especially  to  be  recommended.  Whole-wheat  bread,  being  more  nour- 
ishing than  white  bread,  is  to  be  preferred.  Do  iiot  eat  the  inside  of 
fresh  bi-ead ;  bread  with  a  hard  crust,  toast,  and  stale  bread  are  more 
easily  digested  and  more  nourishing. 

Eat  slowly,  chew  your  food  well,  take  the  milk  in  small  swallows;  take 
but  little  liquid  during  and  shortly  after  meals.  Keep  your  teeth  in 
good  condition;  use  toothpick  and  brush  after  each  meal. 

Never  take  any  alcoholic  beverages  (wine,  beer,  or  liquor)  without 
special  consent  and  direction  of  your  physician.  Too  much  sweets 
(sugar,  pies,  pastry,  etc.)  should  also  be  avoided,  as  well  as  all  kinds 
of  fried  food. 

Drink  plenty  of  good  pure  water  between  mealtimes  (not  with  meals). 

Do  not  use  tobacco  in  any  form;  smoking  cigarettes  and  inhaling  the 
smoke  is  particularly  injurious. 


INSTRUCTIONS  FOR  PHYSICIAN'S   USE  IN  PRIVATE   PRACTICE    817 

Special  Diet 


Directions  Concerning  Baths  and  the  Use  of  Cold  Water 

Take  a  short,  warm  bath  once  a  week,  followed  by  a  rapid  sponging  with 

cooler  water  and  a  vigorous  rubbing  with  a  rough  towel. 
Wash  your  neck  and  chest  every  morning  with  cold  water. 


Special  Directions  for  the  Use  of  Cold  Water 


Special  Directions  for  Breathing  Exercises 

Take  exercise  No.  Repeat  times,  every  hour.     These  exer- 

cises are  to  be  taken  near  the  open  window  or  outdoors. 


Special  Directions  for  Walking,  Riding,  and  Other  Exercises 


Special  Medical  Advice 


818  APPENDIX   V 


Special  Advice  for  the  Patient,  N^urse,  and  Family 

Any  intercurrent  trouble  such  as  fever,  indigestion,  diarrhea,  constipa- 
tion, increased  cough,  pain,  reddish  expectoration,  or  hemorrhage, 
should  be  at  once  reported  to  the  physician.  Do  not,  however,  be 
alarmed  if  a  hemorrhage  occurs,  as  it  is  but  one  of  the  phases  of  the 
disease  and  does  not  lessen  the  chances  for  recovery.  Let  the  patient 
remain  quiet  on  a  reclining  chair  or  on  the  bed,  and,  until  the  arrival 
of  the  physician,  place  a  cold  compress  or  ice  bag  over  the  heart.  In 
case  of  fever,  particularly  when  it  is  as  high  as  100°  F.  or  more,  it  is 
best  for  the  patient  to  go  to  bed  and  await  instructions  from  the 
physician. 

A  careful  and  obedient  patient  has  all  possible  chances  of  getting  well, 
while  he  who  is  careless  and  disobedient  may  forfeit  all  possibility  of 
recovery. 

To  All  Whom  it  May  Concern: 

The  careful,  clean,  and  conscientious  consumptive,  who  is  trained  in  the 
prevention  of  the  disease,  is  not  dangerous  to  those  with  whom  he 
may  live  and  work. 

,  M.D., 

Attending  Physician. 


APPENDIX   VI 

FOEMULAEY   FOR  THE   SYMPTOMATIC   TREATMENT    OF 
PULMON^ARY    AND    LARYNGEAL    TUBERCULOSIS 

COMPILED   BY  S.   A.    KNOPF,   M.D. 

The  following  formulary  is  that  principally  used  in  the  Clinic  for 
Pulmonary  Diseases  of  the  New  York  Health  Department,  with  which 
I  have  the  honor  to  be  associated.  This  compilation  of  prescriptions 
was  arranged  for  the  following  reasons :  Shortly  after  the  inauguration 
of  our  clinic,  I  found  tliat  among  the  twelve  physicians  comprising  the 
attending  staff,  while  there  was  almost  a  unanimity  concerning  principal 
drugs  which  might  be  of  value  in  the  s}Tnptomatic  treatment  of  pul- 
monary tuberculosis,  there  was  no  unanimity  as  to  the  best  method  to 
combine  or  administer  them.  There  was  also  a  slight  tendency  among 
some  of  the  staff  to  write  too  many  prescriptions.  All  of  the  attending 
physicians  were  men  experienced  in  general  practice,  and  a  number  of 
them  had  had  special  training  in  tuberculosis.  To  limit  the  number 
of  prescriptions,  to  simplify  their  composition,  and  to  select  those  which 
in  the  experience  of  my  staff  and  myself  had  proven  of  real  value,  we 
came  together  and  discussed  the  matter  at  length.  We  proceeded  as 
follows :  Each  one,  for  example,  proposed  his  favorite  remedy  for  cough, 
and  after  he  had  defended  his  reason  for  the  preference  of  his  remedy, 
I  ventured  to  propose  my  own  favorite  prescriptions,  and  gave  my 
reasons  for  their  preference.  We  then  decided  by  vote  which  to  accept. 
There  was  never  a  heated  dispute  about  any  drug  or  prescription,  but 
only  careful  and  deliberate  discussion,  and  when  we  decided  on  any 
particular  recipe  it  was  always  on  a  unanimous  vote.  This  formulary 
has  now  been  in  use  for  a  number  of  years,  and  it  would  seem  that  it  has 
proved  quite  satisfactory  to  physicians  and  patients.  I  have  made  a  few 
changes  and  added  a  few  other  prescriptions  which  have  proved  of  value 
in  private  practice. 

In  addition  to  this,  I  wish  to  say  that  most  of  these  prescriptions 
I  have  also  used  in  my  service  in  the  Riverside  Sanatorium  for  Pulmo- 
nary Diseases  of  the  New  York  Health  Department,  where  the  majority 
of  patients  received  are  in  the  advanced  stages.  It  has  been  found  to 
be  of  great  economy,  by  our  department,  to  have  the  majority  of  these 

819 


820  APPENDIX   VI 

drugs  put  up  by  the  department's  pharma-  ^  ^^ 

cist.  The  prescribing  and  filling  of  the  dis- 
pensary physicians'  prescriptions  according 
to  number  is,  of  course,  a  great  saving  of  time. 

TO    COMBAT    COUGH 

Inhalation 
T^   Olei  eucalypti,  'j 

Spirit,  chloroformi,  >  aa. .  .  .   oijss.  i  *:^ 

Menthol,  J  /\  "^"^-^co 

M.      Sig. :   Inhale   five   to   fifteen   drops      /  \          "' 

with  aid  of  inhaler  or  handkercliief  throe  to    />'-'^w^        \./f 

four  times  daily  for  several  minutes  at  a  time. 

Fig.  5.— Bevekley  Robinson's 

:^   Creosoti    ( beech  wood ),  ^  Zinc  Inhaleh. 

Spirit,  chloroformi,        ^  aa oijss. 

Spirit,  rectif.,  J 

M.     Sig. :  Inhale  ten  to  fifteen  drops  with  aid  of  inhaler  or  hand- 
kerchief three  to  four  times  daily  for  several  minutes  at  a  time. 

]^   Menthol gr.  v ; 

Creosoti gtt.  v ; 

Olei  olivse    A  Sj- 

M.     Sig. :  Warm  and  inject  one  drachm  into  larynx  daily  with  the 
aid  of  intratracheal  syringe. 

Cough  Mixtures 

^  Mist,  glycyrrhizae  compos §vj. 

Sig. :  One  half  to  one  tablespoonful  every  two  to  three  hours. 

^  Heroinae  hydrochlor gr.  i j ; 

Acid,  sulphuric,  dil TIXxlv ; 

Glycerinse    §j ; 

Aq.  laurocerasi,        )     _ 

Q  •     •         Ma oiv ; 

byrup.  pruni  virg.,  j 

Aquae  destillatse q.   s.   ad.  §iij. 

M.     Sig. :  One  teaspoonful  three  or  four  times  a  day. 

!l^   Codeinae gr.  iij ; 

Acid,  sulphuric,  dil .  . Tn,xlv; 

Glycerinae  gj ; 

Aq.  laurocerasi,  )     _ 

a  .     .         V  aa 3iv; 

Syrup,   pruni  virg.,  j 

Aquae  destillatae q.  s.  ad.  .^iij. 

M.     Sig. :  One  teaspoonful  three  or  four  times  a  day. 


FORMULARY  FOR  SYMPTOMATIC  TREATMENT  OF  TUBERCULOSIS   821 

I^   Elixir  terpini  hydrat 5j ; 

Glycerinae 3iv ; 

Syrup,  pruni  virgin 5jss. 

M.     Sig. :  One  teaspoonful  every  three  to  five  hours. 

Stokes's  Expectorant 
^  Ammon.   carbonat gr.  xvj ; 

Extr.  fluid,  senegs.  )  _  _ 

aa 3ss ; 


Extr.  fluid,  scilla?, 

Tinct.  opii  camphorat oiij ; 

Syrup,  tolutani q.  s.  ad.  5ij. 

M.     Sig. :  A  teaspoonful  every  two  to  four  hours  as  needed  to  relieve 
distressing  and  suffocating  cough. 

For  Cough   ivhen  there  is  at  the  Same  Time  Dyspneic  or  Asthmatic 

Difficulty 
I^   Ammon.  brom.. 


.  ,  ,         ^  aa 31 ; 

Ammon.  chlor..  ' 

Tinct.  lobelife 3j ; 

Spirit,   ether,   co ^ss ; 

SjTup.  acacire q.  s.  ad.  qIIj. 

M.     Sig. :  One  teaspoonful  every  three  to  four  hours. 

'  ANODYNES 

For  Acute  Pleuritic  Pains  with  Fever 

B   Heroinfe,  |   __  ^ 

Xo.  XII  in  tablet  form,  [  '^^ ^^*  ^^* 

Sig.:  One  tablet  three  or  four  times  a  day. 

I^  Morphinae  sulphat.,  )  __ 

Xo.  IV  in  tablet  form,  ^^ ^'    ^' 

Sig. :  One  at  bedtime. 


•ZA 


1^  Tinct.  aconit.  rad., 

Tinct.  opii  deodorat.,  '        '^^ 

M.     Sig. :  Five  drops  in  water  every  hour  or  two. 
Note. — For  pleuritic  pain. 

For  Local  Use 
IJ   Tincturae  iodi. 
Sig. :  Use  externally  with  a  brush,  as  directed. 


822  APPENDIX    VI 

I^   Linimenti  chloroformii. 

Sig. :  Eub  over  painful  parts,  as  directed. 

I^   Emplastri  sinapis, 

Xo.  1. 
Sig. :  Apply  as  directed. 

I^   Zinc-oxid  adhesive  plaster  (for  strapping  in  acute  pleurisy), 

TO  COMBAT  HYPEEiDROsis    {Xight  Sweats) 
J^   Atropine  sulphat., 


Xo.  YI  in  tablet  form,  [  '^'^ ^^"  ^^"»" 

Sig. :  One  tablet  at  bedtime. 

I^   Pulv.  agarici 3j. 

In  pulv.  Xo.  XII  div. 
Sig.:  One  powder  ever}'  two  hours  (for  three  doses),  if  necessary. 

I^   Pyraniidon  camphorat.    (neutral) 3j. 

Div.  in  chart.  Xo.  VIII. 
Sig.:  One  at  bedtime. 

TO    ro:MBAT    HEMOPTYSIS 

I^   Stypticin    gr.  i  j ; 

Pliimbi  acetas   gr.  xviij ; 

Pulv.  digitalis gr.  ix ; 

Pulv.  opii gr.  V. 

M.  Ft.  capsulas  Xo.  9.     Sig. :  One  every  four  hours. 

1^   Acid,  gallici    5ij ; 

Acid,  sulph.  aronuit .   5j ; 

Glycerins    oj ; 

AqUcP q.  s.  ad.  gvj. 

M.     Sig. :  One  teaspoonful  every  hour  or  two,  as  needed. 

TO    COMBAT   HEART   C0:MPLICATI0XS 

^   Tinct.  digitalis    TTlxxx ; 

Aquffi  destillata^ q.  s.  ad.  5ij. 

M.     Sig. :  One  teaspoonful  three  or  four  times  a  day. 
Note. — For  weak  and  irregular  heart. 


FORMULARY  FOR  SYMPTOMATIC  TREATMENT  OF  TUBERCULOSIS    823 

For  Tendency  io  Heart  Failure 

^   Caffeine  citratae   gr.  ix ; 

Acetanilidi gr.  vj ; 

Sodii  bicarbonat ojss. 

Div.  in  capsulas  No.  IX. 
Sig. :  One  capsule  every  three  to  four  hours,  as  required. 

^   Sodii  bromidi    oij ; 

Chlorali  hyd gr.  xl ; 

Aquge  destillata^ q.  s.  ad.  5ij. 

M.     Sig. :  One  teaspoon ful  in  a  little  water  three  times  a  day. 
Note. — For  extra  high  tension  pulse,  one  dose  at  bedtime. 


TO    COMBAT    CONSTIPATION 

I^   Hydrarg.  cldor.  mite,        )   __  j^ 

Xo.  XII  in  tablet  form,  j"  '^'^ ^'  *' 

Sig. :  One  every  hour  until  free  movement  is  produced. 
Note. — For  occasional  constipation. 

I^    Olei  ricini   B^S- 

Sig. :  Take  as  directed. 

Note. — For  occasional  constipation. 

]^   Pluto  concentrated  spring  water. 

Sig. :  Two  to  four  tablespoonfuls,  diluted  in  cold  water,  upon  rising. 

IJ   Sodii  salicylatis   3i j ; 

Sodii  phosph 3v ; 

Potass,   sulph ad.  ,^i j ; 

Pulv.  zingiberis    3j. 

M.  Sig. :  A  teaspoonful  in  hot  water,  early  in  the  morning. 


J.- 

4  J 


Pil.  Lapacticae 

^  Aloin   gr. 

Strychnina'    gr.  ^; 

Extr.  belladonna'   gr.  i ; 

Ipecacuanhae    gr.  ■^. 

Sig. :  One  to  two  pills  at  bedtime. 


824  APPENDIX   VI 

I^   Ext.  cascarae  sagrad.  fid.,   |  _. 

Elixir  simplicis,  j       ^■'* 

Sig. :  Two  teaspoonfuls  at  bedtime. 

Note. — The  three  preceding  remedies  should  be  given  alternately  in 
chronic  constipation,  and  aided  by  appropriate  diet. 

TO    COMBAT    DIARRHEA 

I^   Piilv.  opii   gr.  iij ; 

Bismuth,   subnitrat    5jss ; 

Sod.   bicarbonat    gr.  xlv. 

M.  T)iv.  in  chart.  No.  IX.     Sig. :  One  capsule  three  or  four  times  a 
day. 

Note. — For  ordinary  diarrhea   (due  to  dietetic  errors)   after  having 
evacuated  intestinal  tract. 

I^   Pulv.  opii  . gr.  vj ; 

Acid,  tannici   5j. 

M.  Div.  in  chart.  No.  XII. 

Note. — For  chronic  diarrhea,  seemingly  due  to  tuberculous  invasion 
of  the  intestinal  tract. 


TO    COMBAT   OTHER  DIGESTIVE    DISTURBANCES 

I^   Phenyl,  salicylat gr.  xxiv. 

Div.  in  capsulas  No.  XII. 
Sig. :  Take  one  capsule  one  half  hour  before  each  meal. 

I^  Liquor,  pepsini o^^ij- 

Sig.  One  to  two  teaspoonfuls  after  each  meal. 

1^   Pilularum  creosoti,  ]  __ 

(Enteric  coated)    No.   XYIII,  j  '^'^ ^'  ^^' 

Sig. :  One  three  times  a  day  after  meals. 

I^   Peptenzyme,  ^ 

Sodii  bicarbonat.,  >-  aa 5iv ; 

Pulvis  aromatici,   J 

Pulvis  rhei   3J. 

Ft.  pulvem  et  div.  in  caps.  No.  XXIV. 
Sig. :  One  after  each  meal. 


FORMULARY  FOR  SYMPTOMATIC  TREATMENT  OF  TUBERCULOSIS    825 
TO    COMBAT    ANOREXIA    AND    EMACIATION 

Tonics 

J^  Tinct.  niicis  vomicae   3ij ; 

Tinct.    cinchonae,  )_  ^ . 

Tinct.  colomba^,    [  '^'^ ^'' ' 

Tinct.  gentianas .  .  .* q.  s.  ad.  §iv. 

M.  Sig. :  One  teaspoonful  in  three  tablespoonfuls  of  water  before 
meals. 

I^   Misturae  rhei  et  sodii 5vj. 

Sig. :  Two  teaspoonfuls  after  meals. 

I^   Tinct.  nucis  vomica?   oij ; 

Ext.  fi.  cascarffi  sagrad. 

Mist,  rhei  et  sodii ^iy. 

M.     Sig. :  Two  teaspoonfuls  after  principal  meals. 
Note. — For  anorexia  with  constipation. 

I^  Liquor,  potassii  arsenitis 3ijss ; 

Aquae  destillata ovss. 

M.  Sig. :  Nine  drops  in  one  tablespoonful  of  water  after  each  meal 
for  one  week ;  increase  to  twelve  drops  the  second  week  and  fifteen  drops 
the  third  week.  Then  recommence  with  nine  drops  and  increase  as 
before. 

TO    COMBAT   ANEMIA 

^   Ovoferrin 5vj. 

Sig. :  Two  teaspoonfuls,  before  principal  meals,  in  wineglassful  of 
water. 

I^   Syrupi  f erri  iodidi 5i j ; 

Syrupi  zingiberis   .^J  j 

AqucU  destiilatffi q.  s.  ad.  §vj. 

Sig. :  A  tablespoonful  three  times  a  day. 

I^   Pil.  ferri  carbonatis  (Blaud's  pills)   No.  XXIV. 
Sig. :  Two  pills  after  each  of  the  principal  meals. 

Alteratives 

^   lodoformi    gr.  xx ; 

Strychninae  sulphat gr.  | ; 

Ichthyol oj. 

M.  Div.  in  caps.  No.  XX.  Sig. :  One  capsule  after  each  of  the  three 
principal  meals. 


826  APPENDIX   VI 

^   Calcii  carbonat.,     ]  __  _ 

Caleii    phosphat.,  C      

Sodii  chloridi    3ij. 

M.  Div.  in  chart.  No.  XXX.  Sig. :  To  be  taken  in  wafers  after  prin- 
cipal meals. 

Note. — Indicated  when  there  is  intense  demineralization  of  the  sys- 
tem and  formation  of  cavities.  The  withholding  of  all  acids  while  these 
powders  are  given  will  add  to  their  efficiency. 

]^   Sohit.  potassii  iodidi   (saturated) ^ij. 

Sig. :  Five  drops  or  more  three  times  daily,  as  directed. 
Note. — Indicated   when   a  syphilitic   condition  seems  to  have  been 
added  to  a  tuberculous  infection,  or  vice  versa. 

Nutritives 

I^   Iron-tropon    ^^j. 

Sig. :  One  to  two  teaspoonfuls  three  or  four  times  a  day,  in  milk  or 
water. 

I^   Maltine  with  hypophosphites   B^iij- 

Sig. :  Two  to  four  teaspoonfuls  after  meals. 

Jji  Maltine  with  cod-liver  oil S^iij- 

Sig. :  Two  to  four  teaspoonfuls  after  meals. 
The  Malzime  preparations  are  equally  good. 

I^   Emulsionis  sevi  et  olei  comp o'^iij- 

Sig. :  One  half  tablespoonful  three  times  daily. 

TO    COMBAT    FEVER 

R   Pil.    quininfc   sulphat..  )   .. 

V  aa  ST    11 

No.  XII,  sugar  coated,  j  *=       ■" 

Sig. :  Take  as  directed. 

Note. — In  addition  when  rest,  aero-,  and  hydro-therapeutic  means 

do  not  suffice. 

TO    COMBAT    IXSOMNIA 

I^   Chloral,  hydratis 3iij ; 

Syrupi  tolutani   5j ; 

AquEe  destillat q.  s.  ad.  §iv. 

M.     Sig. :  A  tablespoonful  at  bedtime. 

Note. — Should  only  be  resorted  to  when  the  insomnia  is  due  to  a 

purely  nervous  condition,  and  aero-,  In^dro-,  and  hygienic  means  have 
failed. 


FORMULARY  FOR  SYMPTOMATIC  TREATMENT  OF  TUBERCULOSIS    827 

I^   Veronal    3j. 

Div.  in  chart.  Xo.  XII. 

Sig. :  One  on  retiring ;  if  necessary,  another  two  hours  later. 


FOR  THE  TREATMENT  OF   LARYNGEAL  TUBERCULOSIS   AND   COMPLICATIONS 

Local  Remedies 
^   Ichthyol,  1 

Ung.  hydrarg.,    ^  aa 3ij ; 

Ung.  bell  a  don.,  J 

Ung.   petrol 5]. 

M.     Sig. :  Apply  freely  twice  daily. 

Note.— For  glandular  enlargement. 

I^   Acidi  boric 3j ; 

Glycerinse  acidi  tannici o^s ; 

Olei  gaultheriffi TT^x  ; 

Aq.  destillat q.  s.  ad.  giv. 

M.     Sig. :  To  be  used  in  atomizer  after  cleaning. 

^   Menthol gr.  xx ; 

Camphora? gr.  vj ; 

Albolene q.  s.  ad.  3j- 

Sig. :  To  be  used  in  oil  atomizer  after  cleaning  nose. 

I^   Menthol   gr.  xxv ; 

01.  olivffi   q.  s.  ad.  5J. 

Sig. :  For  injection  or  atomizing  into  larynx. 

I^    Sodii  chlorid "^ly, 

Sodii  bicarbonat ^iv. 

M.     Sig. :  Dissolve  small  teaspoonful  in  pint  of  warm  water  and  use 
for  cleaning  throat. 

I^   Seller's  tablets. 
Sig. :  As  directed. 

I^   Potassii  permanganat gr.  ij. 

No.  XXIV  in  tablet  form. 

Sig. :  As  directed. 


828 


APPENDIX   VI 


For  Internal  Use 

I^   Cocainge  hydrochloridi    gr.  ij ; 

Morphinae  sulphatis    gr.  iv ; 

Orthoform gr.  Ixxx. 

M.  Ft.  tablets  No.  XVI.     Sig. :  Dissolve  one  in  mouth  slowly,  about 
fifteen  minutes  before  eating;  used  in  odynphagia  of  laryngeal  ulcers. 

^  Tinct.  ferri  chlor TTtxxx ; 

Hydrargyri  chlor.  corros gr.  X-; 

Tinct.   aconiti    TT\,xx ; 

Sacchari  lactis q.  s.  ad.  tabl.  No.  X. 

M.     Sig. :  Take  one  and  have  it  dissolve  on  tongue. 
Note. — For  acute  inflammation  of  tonsils  and  pharynx. 

I^   Tincturae  ferri  chloridi Sijss ; 

Potassii  chlorat oss ; 

Glycerinae   3j  j 

AqufB  destillatae q.  s.  ad.  ^iv. 

M.    Sig. :  Take  one  teaspoonf  ul  in  tablespoonf  ul  of  water  every  three 
or  four  hours. 

Note. — For  acute  inflammation  of  tonsils  and  pharynx. 


Fig.  6. — A  Laryngeal  Medicator,  Devised  by  Mannheimer  and  Yankauer. 
Can  be  used  for  watery  and  oily  solutions.  Indicated  particularly  for  dispensary 
and  private  practice,  when  patients  cannot  be  kept  under  constant  medical  super- 
vision. Those  suffering  from  painful  laryngeal  tuberculosis  can  anesthetize  their 
own  larynx,  especially  before  eating.  Of  medicaments  orthoform  by  itself  or 
mixed  with  iodoform  in  equal  proportions  (emulsified  in  a  yolk  of  egg)  are  rec- 
ommended.    (From  Knopf  and  Huey,  "Notes  on  Laryngeal  Tuberculosis.") 


FORMILARY  FOR  SYMPTOMATIC  TREATMENT  OF  TUBERCULOSIS    829 

The  following  are  four  standard  disinfectants  which  are  simple, 
cheap,  and  reliable.  They  are  highly  recommended  in  the  circular  issued 
by  the  Illinois  State  Board  of  Health  on  the  subject,  "  The  Cause  and 
Prevention  of  Consumption  '" : 

Standard  Disinfectant  No.  1 
Four-Per-Cent  Solution  of  Chlorid  of  Lime 

Dissolve  chlorid  of  lime  of  the  best  quality  in  water,  in  proportions 
of  six  ounces  of  lime  to  one  gallon  of  water. 

This  is  one  of  the  strongest  disinfectants  known.  Discharges  from  the 
bowels  of  a  patient  suffering  from  a  contagious  or  infectious  disease 
should  be  received  in  a  vessel  containing  this  solution,  and  allowed  to 
stand  for  an  hour  or  more  before  being  thrown  into  the  vault  or  water- 
closet.  Discharges  from  the  throat  or  lungs  should  be  received  in  a  vessel 
containing  this  solution. 

Chlorid  of  lime  in  powder  may  be  used  freely  in  privy  vaults,  cess- 
pools, drains,  sinks,  etc. 

Instead  of  the  solution  of  chlorid  of  lime,  carbolic  acid  may  be  used 
for  the  same  purposes,  in  a  strength  of  6i  ounces  to  the  gallon  of  water. 
This  makes  a  five-per-cent  solution  of  carbolic  acid. 

Standard  Disinfectant  INTo.  2 
Bichlorid  of  Mercury  (1-500) 

Dissolve  corrosive  sublimate  and  muriate  of  ammonia  in  water,  in  the 
proportion  of  two  drachms  (120  grains — i^  ounce)  of  each  to  the  gallon 
of  water.     Dissolve  in  a  wooden  tub,  barrel,  or  pail,  or  an  earthen  crock. 

Use  for  the  same  purpose  and  in  the  same  way  as  No.  1.  Equally 
effective  but  slower  in  action,  so  that  it  is  necessary  to  let  the  mixture 
(disinfectant  and  infected  material)  stand  for  about  four  hours  before 
disposing  of  it.  This  solution  is  odorless,  while  chlorid-of-lime  solution 
is  often  objectionable  in  the  sick  room  on  account  of  its  smell. 

Standard  Disinfectant  No.  3 
Bichlorid  of  Mercury  (1-1,000) 

Dissolve  one  drachm  (60  grains — J  ounce)  each  of  corrosive  subli- 
mate and  muriate  of  ammonia  in  one  gallon  of  water.  Dissolve  in  a 
wooden  tub,  barrel,  or  pail,  or  earthen  crock. 

Use  for  the  disinfection  of  soiled  underclothing,  bed  linen,  etc.  Im- 
merse the  articles  for  four  hours,  then  wring  them  out  and  boil  them. 
This  solution  is  excellent  for  wetting  the  floors  of  offices,  stores,  work- 
shops, halls,  and  school  rooms,  before  sweeping. 


830  APPENDIX   VI 

Mixed  with  an  equal  quantity  of  water  this  solution  is  useful  for  wash- 
ing the  hands  and  general  surfaces  of  the  bodies  of  attendants. 

Chlorid  of  lime,  carbolic  acid,  and  corrosive  sublimate  are  deadly 
poisons. 

Standard  Disinfectant  No.  4 

Milk  of  Lime   (Quick-lime) 

Slake  a  quart  of  freshly  burnt  lime  (in  small  pieces)  with  three 
fourths  of  a  quart  of  water — or,  to  be  exact.  60  parts  of  water  by  weight 
with  100  of  lime.  A  dry  powder  of  slaked  lime  (hydrate  of  lime)  results. 
Make  milk  of  lime  not  long  before  it  is  to  be  used  by  mixing  one  part 
of  this  dry  hydrate  of  lime  with  eight  parts  (by  weight)  of  water. 

Air-slaked  lime  is  worthless.  The  dry  hydrate  may  be  preserved  some 
time  if  it  is  inclosed  in  an  air-tight  container.  Milk  of  lime  should  be 
freshly  prepared,  but  may  be  kept  a  few  days  if  it  is  closely  stoppered. 

Quick-lime  is  one  of  the  cheapest  of  disinfectants.  The  solution  can 
take  the  place  of  chlorid  of  lime,  if  desired.  It  should  be  used  freely  in 
quantity  equal  in  amount  to  the  material  to  be  disinfected.  It  can  be  used 
to  whitewash  exposed  surfaces,  to  disinfect  excreta  in  the  sick  room  or  on 
the  surface  of  the  ground,  in  sinks,  drains,  stagnant  pools,  etc. 

In  addition  I  desire  to  describe  the  manner  in  which  our  New  York 
City  Health  Department  makes  use  of  formaldehyd  gas  to  disinfect 
rooms  and  wards  which  have  been  occupied  by  tuberculous  patients : 

To  liberate  the  formaldehyd  gas,  take  to  every  pound  of  lime  eight 
ounces  of  a  mixture  (formaldehyd,  forty-per-cent  solution,  two  parts, 
and  aluminum  sulphate,  saturated  solution,  one  part)  of  formaldehyd, 
and  aluminum  sulphate  is  added.  The  amount  of  formaldehyd  solution 
used  by  the  department  is  one  ounce  for  every  100  cubic  feet  of  space.  It 
is  necessary  that  the  formaldehyd  be  forty-per-cent  solution,  and  that  the 
lime  be  absolute  quick-lime,  if  good  results  are  to  be  obtained.  If  the 
lime  appears  streaked  with  red  after  addition  of  the  formaldehyd,  it  indi- 
cates that  a  good  part  of  the  formaldehyd  has  been  lost  by  polymerization. 

Preliminary  to  the  liberation  of  the  gas  it  is  advisable  to  prepare  the 
room  and  articles  to  be  disinfected  in  the  manner  recommended  by  Novy 
and  Waite,  which  is  as  follows: 

1.  All  cracks  or  openings  in  the  plaster  or  in  the  floor,  or  about  the 
door  or  windows,  should  be  calked  tight  with  cotton  or  with  strips  of 
cloth.  2.  The  linen,  quilts,  blankets,  carpets,  etc.,  should  be  stretched  out 
on  a  line  in  order  to  expose  as  much  surface  to  the  disinfectant  as  possi- 
ble. They  should  not  be  thrown  into  a  heap.  Books  should  be  suspended 
by  their  covers,  so  that  the  pages  will  fall  open  and  be  freely  exposed.    3, 


FORMULARY  FOR  SYMPTOMATIC  TREATMENT  OF  TUBERCULOSIS    831 

The  walls  and  the  floor  of  the  room,  and  the  articles  contained  in  it, 
should  be  thoroughly  sprayed  with  water.  If  masses  of  matter  or  sputum 
are  dried  down  on  the  floor,  they  should  be  soaked  with  water  and  loos- 
ened. No  vessel  of  water  should,  however,  be  allowed  to  remain  in  the 
room.  4.  One  hundred  and  fifty  cubic  centimeters  (five  ounces)  of  the 
commercial  forty-per-cent  solution  of  formalin  for  each  one  thousand 
cubic  feet  of  space  should  be  placed  in  the  distilling  apparatus  and  be  dis- 
tilled as  rapidly  as  possible.  The  keyhole  and  spaces  about  the  door 
should  then  be  packed  with  cotton  or  cloth.  5.  The  room  thus  treated 
should  remain  closed  at  least  ten  hours.  If  there  is  much  leakage  of  gas 
into  the  surrounding  rooms,  a  second  or  third  distillation  of  formaldehyd 
should  be  made  at  intervals  of  two  or  three  hours. 


APPENDIX    VII 

DEVICES    FOR    THE    PREVENTION    OF    TUBERCULOSIS 
By  S.  a.  KNOPF,  M.D. 

The  following  illustrations  of  various  devices  for  the  prevention  and 
treatment  of  tuberculosis  have  proved  most  useful  in  my  experience. 
I  do  not,  however,  wish  to  say  that  there  are  not  any  number  of  any 
other  kinds  of  sputum  receptacles  which  are  good,  or  devices  for  the 
rest  cure  in  the  open  air,  tents  and  tent  houses,  as  practical  and  as 
useful  as  those  here  illustrated.  There  is  an  overwhelmingly  large 
amount  of  such  devices  at  the  disposal  of  those  interested  in  the  prob- 
lem, and  to  illustrate  and  describe  them  all  would  take  much  more 
than  the  space  reserved  for  such  purposes  in  a  book  of  this  kind. 


Fig.  7. 


Fig.  8. 


Figs.  7  and  8. — Improved  Wooden  Box  for  Sending  Specimens  of  Sputum  to 
THE  Laboratory  for  Examination.     (Dr.  Hart.) 


832 


DEVICES   FOR   THE   PREVENTION   OF   TUBERCULOSIS         S33 


Fk;.  11. 


Figs.  9  to  11. — Knopf's  Pocket  Flask,  Manageable  with  One  Hand, 
Showing  Method  of  Use. 
54 


834 


APPENDIX    VII 


Fiti.  12. 


Fig.  14. 


Fig.  lo. 


Fig.  1G.  Fig.  17. 

Figs.  12  to  17. — Pocket  Sputum  Flasks.  (12)  Dettweiler's.  (13)  With  screw  cap 
top  and  bottom.  (14)  Knopf's,  (lo)  Liebe's.  (16)  With  spring  top.  (17)  With 
spring  side  opening  and  screw  top  for  emptying. 


DEVICES   FOR  THE   PREVENTION   OF   TUBERCULOSIS         835 


Fig.  19. 


Mi     • "'~'''^jof''*lili 


Fig.  18.  Fig.  2U. 

Figs.  IS  to  20. — Three  Different  Kinds  of  P.\per  Pocket  Cuspidors. 

They  are  destroyed  after  use. 


Pocket 
Sputum  Slide  Case. 


Fig.  21. — Pocket  Sputum  Case  of 
Paper. 


Fig.  22. — Pasteboard  Sputum  Cup 
FOR  Bedside.     (Kny-Scheerer.) 


Fig.  2.'^. — Aumixtm  ok   Porcel.a.in 
Spit  Cup  for  Bedside. 


836 


APPENDIX   VII 


Fig.  24. — Large  Hygienic  Pasteboard  Cuspidor  for  use  in  Factories,  Public 

Buildings,  etc. 


Fig.  25. 


Fig.  26. 


Figs.  25  and  26. — Pasteboard  Filler  and  Tin  Frame  Holder  of  an  Individual 

Cuspidor  (Portable). 


Fig.  27. — Crexl\tory  Basket  and  Fillers.     For  sanatoria  or  public  l^uildings. 


DEVICES    FOR  THE   PREVENTION   OF   TUBERCULOSIS         837 


Fig.  28. 


Fig.  29. 


Fio.  30 

FUi.    2S     to     :;().      -SaMTAUY      ClTSI'IDOKS     TO 

UK  AriACHKi)  TO  \\ai.l,  Ci.OSKI),  ()iM;>f 

AND    IN    I'SK. 


Fui.  31. — Wall  Cuspidok. 
(Predohl.) 


APPENDIX   VII 


Fig.  32. 


Fig.  33. 


Fig.  34. 


Fig.  35. 


DEVICES   FOR   THE   PREVENTION    OF   TUBERCULOSIS         830 


Fig.  :i6. 


Fig 


Figs.  32  to  37. — Elevated  Cuspidor.s  for  use  in  S.a.xatoria  or  Public  Buildings. 
(Designed  by  S.  A.  Knopf.)  (34)  With  waste  and  flushing  arrangement  for 
use  on  streets.     (35)  Similar  with  cover. 


Fig.  38. — ^Telephone  Fitted  with  Paper  Screen  to  Prevent  Infection. 
(Recoininendcd  by  S.  A.  Knopf.) 


840 


APPENDIX   VII 


I 

c 

Fig.  39. — Suction  Mask  for  the  Treat- 
ment OF  Pulmonary  Tuberculosis  by 
Hyperemia.  (E.  Kuhn.)  Obstruction 
of  inspiration  with  free  expiration.  (.4) 
Adjustable  nasal  opening  for  inspiration. 
(6)  Valve  in  nasal  chamber  for  expira- 
tion. (C)  Valve  in  oral  chamber  for 
expiration,  can  be  taken  off  to  allow 
free  expiration  in  case  inspiration  is 
made  through  nose.  (D)  Partition  be- 
tween nasal  and  oral  chamber  with  ad- 
justable opening  to  be  used  when  nasal 
respiration  is  not  practicable. 


Fig.  40. — Suction  Mask  Adjusted 
TO  Face.  (From  Knopf  and 
Huey,  "Notes  on  Laryngeal 
Tuberculosis.") 


HUHTDlFlER" 

1  FLOOD  DEGISTER 

2\VATEDTANK  '■ 
3  SHEETS  OF 
OTTON  FELT. 


Fig.  41. — Humidifier  for  Hot-Air 
Registers. 


Fig.  42.  —  Hair  Hygrometer 
Reglstering  Directly  Rel- 
ative Humidity. 


DEVICES   FOR   THE   PREVENTION   OF   TUBERCULOSIS         S41 


Fig.  43. — Reclining  Chair  of  Bamboo  with  Patient  in  Sleeping  Sack. 


Fig.  44. — Reclining  Chair  of  Steel  Tithing. 


55 


842 


APPENDIX   VII 


Fig.  45. 


Fig.  46. 


t  mi^- 

m 

hi 

Fig.  47. 

Figs.  45  to  47. — Portable  Cot,  Occupying  Little  Space  when  Folded. 

(Dr.  Weicker.) 


DEVICES   FOR  THE   PREVENTION   OF   TUBERCULOSIS         843 


Fig.  48. — Rest  Cure  at  Home,  in  a  Wicker  Chair,  Padded  on  the  Inside. 


Fig.  49. — Half-tknt  with  Patient  Resting  on  Metal  Reclining  Chair 
Taking  the  Rest  Cure.     (S.  A.  Knopf.) 


844 


APPENDIX   VII 


Fig.  50. — Steel  Frame  for  Half-tent  Folded  Together. 
(S.  A.  Knopf.) 


Fig.  51. — Portable  Tent  Cot,  Opened  and  Folded. 


DEVICES   FOR   THE    PREVENTION    OF   TUBERCULOSIS         845 


Fig.  32. — A  Simple  Inexpensive  Tent  for  Tuberculous  Patients. 
(Dr.  H.  L.  Ulrich.) 


846 


APPENDIX    Vll 


Air  Inlet  Near  Floor. 


Frost  Awnings  Open. 


Front  Awnings  Closed  Roof  Ventilators. 

Fig.  53. — Various  Ventilating  Devices  of  a  Tent.     (Tucker.) 


DEVICES  FOR  THE   rREVEiNTlON    OF   TUBERCULOSIS         847 


Fig.  54. — Portable  Cottage.     (Walker.) 


Fig.  55. — ^T'ent  on  Grounds  of  Bellevue  Hospital,  New  Yokk. 


848 


APPENDIX   VII 


Fig.  56. — Irving  Fisher's  Tent. 


Fig.  57. — De.  Biggs's  Adirondack  Tent  House;  it  Can  be  Used  with 
Perfect  Comfort  During  Eight  or  Nine  Months  op  the  Year. 


DE\ICES  FOR  THE  PREVENTION  OF  TUBERCULOSIS    841) 


THh  1^ 


(* -S^CC- 


/^af- 


IHh lAt 


Fig.  58. — a,  6,  c.     Elevations  and  Floor  Pl.\n  of  Dr.  Biggs's  Adirondack 

Tent  House. 


850 


APPENDIX   VII 


rinn 


s^CT/o/r 


'T//T     /-J)     III   j,     m ^ _    ^i/f 


eiOO/>  alf/LT 


DC 


-?r 


Fig.  59. — Plan  and  Section  of  a  Ventilated  Tent. 
(Designed  by  Dr.  Gardiner.) 


DEVICES   FOR  THE   PHEVENTION    OF   TUBEHCUL06IS         S5l 


DETA/LS  OF 


/7//?  OUTLET 


/^^>0/f  /fO/'S^   Td\  /f)^/S£  A  L  Ot^S^  CJ1P 


k\  7 


Fig.  00. — Details  of  Roof  Ventilator  on  a  Tent. 
(Designed  by  Dr.  Gardiner.) 


852 


APPENDIX  VII 


Fig.  61. — Permanent  Arrangement  for  Open-air  Treatment  in  a  Country 

Home. 


Fig.  62.  -Uuiginal  Sluei'ing  Balcony  in  IIanuveh,  Mass. 
Used  since  June,  1898.     (Dr.  Millet.) 


APPENDIX    VIII 

T)TI<yr    LISTS 

By  Members  of  the  Depaktment  of  Household  Administration, 
University  of  Chicago 

Abbreviations  and  Explanations 

P.  =  grams  of  jjroteid. 

F.  =  grams  of  fat. 

C.  li.  :=  grams  of  carbohydrates. 

Cal.  =  caloric  value  of  dish. 

W.  =  actual  weight,  etc.,  of  customary  measure  in  pounds  and  ounces, 
or  fluid  measures  (see  table  of  equivalents  in  Ricliards,  p.  43, 
and  Appendix  I). 

Dish  =  name  of  dish.  Follow  names  given  by  Mrs.  liichards  and  take 
quantities  from  table  of  recipes. 

Cust.  Hfeas.  :=  customary  measures.  Indicated  measures  are  only  sug- 
gestive, and  ought  to  be  replaced  if  deemed  advisable.  Table- 
spoon measure  should  always  mean  "  heaping,"  unless  specifi- 
cally indicated. 

All  measurements  are  level. 

The  cuj)  used  as  the  standard  is  the  measuring  cup  containing  one  half 

pint. 
The  teasj)Oon  is  that  of  average  size,  containing  5  grams  of  water. 

1  cup  ^  IG  tablespoons 
1  tablespoon  =  3  teaspoons 
1  dessertspoon  =  2  teaspoons 
28.3  grams  =  1  ounce 


Abbreviations  : 


c.  =  cup 

thsp.  ^=  tablespoon 
(Is J).  ^=  dessertspoon 
tsp.  =  teaspoon 

853 


854  APPENDIX    VIII 

1  tsp.  5 .  00  grams. 

Water i  I  dsp.  10 .  00  grams. 

1  tbsp.  15.00  grams. 

1  tsp.  4  . 6    grams. 

Sugar -j  1  dsp.  '.» .  20  grams. 

1  tbsp.  13.80  grams. 

1  tsp.  4 .  50  grams. 

Biitter ■!  1  dsp.  <)  .00  grams. 

1  tbsi>.  l.'i.r)0  grams. 

f  1  t.sp.  4.40  grams. 

Oil -j  1  dsp.  8 .80  grams. 

[  1  tb.sp.  i;>. 20  grams. 

1  lump  loaf  sugar G. 79  grams. 

1  lump  domino  sugar 7 .  85  grams. 

Calculated  on  basis  1  dessertspoon  the  equivalent  of  2  tea.spoons,  1  tablespoon 
the  equivalent  of  3  teaspoons,  using  5  gr.  as  unit  weight  of  1  tsp.  water  and  ratio 
between  weights  of  water  and  other  materials;  e.g.,  5  gr.  (wt.  of  1  tsp.  water)  x 
0.92  (average  ratio  between  water  and  sugar) — standard  measure — tsp.  sugar  (4.6 
grams). 


Customary 

Actual 
Weight. 

Nutrients  Yielded. 

1 
Calories. 

Measure. 

Prot. 

Fat. 

C.  H. 

1  cup 

/ 

Coffee  or 
Tea. . . 

leverages. 
f  c.  coffee. 
2  tbsp.  cream. 
2  lumps  (cube) 
sugar. 

Gram.«. 

154.0 

30.0 

14.0 

Grams. 
'0.'75 

Grams. 
"5^5' 

Grams 
14.0 

60 '0 
57.4 

1  cup 

Total 

r  f  c.  coffee. 
Coffee  or  J  2  tbsp.  milk. 
Tea. . .     2   lumps   (cube) 
[          sugar. 

Total 

r  1  c.  milk. 
Cocoa.  ■  •  -^  2  tsp.  cocoa. 
[  1  tsp.  sugar. 

Total 

Milk  a  c.) 

f  J  c.  milk. 
Eggnog.  ]  1  egg. 

[  1  tsp.  sugar. 

198.0 

154.0 
30.8 

14.0 

0.75 
lA)' 

5.5 

i^2 

15.4 

1:5- 
14.0 

117.4 

2i'4 
57.4 

1  cup 

198.8 

184.5 
4.8 
4.6 

1.0 

6.1 
1.0 

1.2 

7.4 
1.4 

15.5 

9.2 
1.8 
4.6 

78.8 

131.6 
24.5 
18.9 

1  tumbler. . 

193.9 

222.6 

184.5 

50.0 

4.6 

7.1 
7.3 

6.1 

6.7 

8.8 

9.0 

7.4 
5.3 

15.6 

11.1 

9.2 

'4^6' 

175.0 
1.59.1 

131.6 

76.8 
18.9 

1  tumbler . . 

Egg 
malted  - 
milk . . 

Total 

' 1  egg. 

1  tbsp.  malted 
milk. 

2  tsp.  chocolate. 
1  t.sp.  sugar. 

^  2  tbsp.  cream. 

239.1 

50.0 

7.0 

4.8 

4.6 

30.0 

12.8 

6.7 

1.0 
0.6 

'6;8' 

12.7 

5.3 

5.4 
2.3 

'5.'5' 

13.8 

0.4 
1.5 
4.6 
1.4 

227.3 

76.8 

56.0 
.30.0 
18.9 
60.0 

Total 

96.4 

9.1 

18.5 

7.9 

241.7 

DIET   LISTS 


855 


Custoiiiary 
Measure. 


1  large. 
1  large. 

6  large. 
1  medium. 
10  shelled. 
10  shelled. 
12  halves. 


Jc. 


§  c.  .small 
serving. 


1  slice. 
1  slice. 
1  slice. 
1  slice. 
1  slice. 
1  slice. 
1  slice. 
1 

1 

1 

1  piece. 

1  piece. 

1  piece. 

1 

1 


Food. 


Actual 
Weight. 


Fruits  and  Nuts.  Grams. 

Orange 251.0 

Banana 152.0 

Strawberries  (hulled) 7.'?  .0 

Prunes  (not  cooked) D.S  .0 

Apple 142.0 

Peanuts 17.0 

Almonds 10 . 5 

Pecans 11.5 

Cereals.  I 

Cere.^l  and  Cre.a.m.  I 

^  c.  rolled  oats 81 . 5 

4  tbsp.  cream 60 . 0 

Total 


141.5 


Cereal    and     Milk     and 
Sugar. 


J  c.  rolled  oats 81.5 

4  tbsp.  milk 61.6 

1  tbsp.  sugar 13.8 


Total 156.9 

Corn     Meal     Mu.sh     and 
Cream.  ; 

J  c.  mush 82 . 3 

4  tbsp.  cream 60 . 0 


Total 142.3 

Corn    Meal   Mush,    Milk 
and  Sugar. 

i  c.  mush 82 . 3 

4  tbsp.  milk 61.5 

1  tbsp.  sugar '  13.8 


Total I   157.6 


Bread  and  Cake. 

Homemade  bread  (thin) . .  . 
Homemade  bread  (thick).  . 

Baker's  bread  (thin) 

Baker's  bread  (thick) 

Toast 

Brown  bread 

Whole  wheat  bread 

Roll,    i^lain,    as   purchase(< 

(medium) 

Roll  (sweet,  large) 

Doughnut  (medium) 

Sponge  cake 

Fro.sted  cake  (2x2) 

Jelly  roll 

Square  wafer 

Butter  for  1  slice  bread .... 
Butter  ball  or  1  cube  butter. 


28.0 
39.0 
17.0 
28.0 
26.0 
69.0 
21.0 

47.0 
66.0 
44.0 
19.0 
44.0 
30.0 
8.3 
4.0 
14.0 


Nutrients  Yielded. 


Prot. 

Grams 

1.5 
1.2 
0.7 
1.0 
0.4 
4.4 
2  2 
I'l 


.28 


2.28 
2.0 


4.28 


1.15 
1.5 


2.65 


1 .  15 
2.0 


Fat. 


Grams. 

0.3 
0.6 
0.4 

o'4 
6.56 

5.8 
8  1 


0.4 
11.0 


11.4 


0.4 
2.5 


2.9 


0.64 
11.0 


11.64 


0.64 
2.5 


C.  H. 


Grams. 

21.3 

21.7 

5.4 

36.0 

15.3 

4.1 

1.8 

1.8 


9.47 
2.8 


,  Calories. 


96.3 
99.5 
28.7 
51.7 
68.1 
96.2 
70.3 
88.2 


51.9 
120.0 


12.27      171.9 


9.47 
3.0 
13.8 


84.30 

43.8 

56.6 


26.27      184.70 


10.0 
2.8 


51.68 
120.0 


12.8        171.68 


10.0 

3.0 

13.8 


51.68 

43.8 

56.6 


3.15 


2.5 
3 . 5 
1.6 
2.6 
3.0 
3.7 
2.0 

4.6 

6.2 

3.0 

1.2 

2.6 

1.5 

0.8 

0.04 

0.1 


3.14      26.8 


0.4 
0.6 
0.2 
0.3 
0.4 
1.2 
0.2 

2.0 
0.5 
9.2 
2.0 
4.0 
2.3 
0.8 
3.4 
12.0 


15.0 
20.8 
9.0 
14.8 
16.0 
32.5 
10.4 

28.2 
39.2 
23 . 4 
12.5 
28.5 
21.0 
6.1 


152.08 


V .) .  5 
105.2 
45.3 
74.1 
81.6 
159.6 
52 . 7 

153.1 

190.8 

193.8 

74.8 

164.7 

113.6 

35.7 

31.8 

112.0 


S5G 


APPENDIX   VIII 


Customary 
Measure. 


Food. 


Soups. 

Consomme 

Cream  of  tomato. . . 
Cream  of  corn .... 
Vegetable  soup. .  .  . 
Cream  of  pea  soup. 

Potato  soup 

Clam  chowder.  .  .  . 


Weight 


Grams. 

177.0 

178.0 

163.8 

179.0 

170.0 

183.5 

245.0 


Fish  chowder 1  245.0 


Cream  of  asparagus. 
Cream  of  celery . .    . . 

White  sauce 

White  sauce 


170.0 
170.00 


Fish  (Dili  Meat. 

Halibut 

Whitefish . 

Creamed  halibut.    . .  . 


Lamb  chop 

Lamb  stew 

Beef  stew 

Veal  stew . 

Hamburg    steak     (without 

bone) 

Lean  steak 

Fat  steak 

Pork  chop 

Pork  tenderloin . 

Mutton  roast 

Veal  roast ... 

Beef  (medium  slice) 

Beef  (large  slice) 

Liver 

Broiled  bacon 

Corn  beef  hash . 

Creamed  dried  beef 

Chicken  breast 

Chicken  upper  joint 

Chicken  drumstick. .        . 

Egg  Preparations 

Whole  egg 

Egg  white 

Egg  yoke 


Egg  omelet 


Creamed  egg' 


1    ntrcr 

'■    ^  }^!-r 

1  tbs|).  milk. . 

1  tbsp.  butter 

Total 


75.0 

75.0 

121.5 

82.0 
110.0 
110.0 
110.0 

85.0 
85.0 
85.0 
85.0 
50.0 
42.7 
59.2 
75.0 

105.0 
25.0 
14.0 
94.0 

106.0 
41.0 
57.0 
60.0 


50.0 
30.0 
20.0 

50.0 

15.4 

4.5 


1  egg 

^  milk 

I  tbsp.  butter 

I  tbsp.  flour.. 

Total.... 


50.0 

81.7 

9.0 

5  0 


NUTRIENT.S   YlKLDKD. 


Prot.  Fat  C.  H 


Grams. 
4.4 
4.5 
4.1 
5.2 
4.4 
6.6 
4.5 

12.9 
4.3 
3.6 
9.9 
1.2 


13.0 

9.0 

14.2 

17.8 

20.5 

5.1 

22.3 

18.8 
23.5 
20.0 
17.0 
14.2 
10.7 
18.0 
19.4 
27.2 
7.7 
3.5 
5.3 
17.7 
13  2 
10.9 
11.5 


6.7 
3.7 
3.1 

6.7 
0.5 
0.05 


Giaii: 


6.80 

6  7 
2.7 
0,1 
0.5 


10.0 


12.5 
3.1 

"4'6' 

10.8 

12.1 

6.8 

5.4 

4.8 

33.0 

4.1 


3.7 
2.6 

7.8 

24.5 

32.8 

4.7 

15.8 

31.2 

6  5 

17.3 

.30.9 

9.8 

9.7 

8.0 

11.1 

15.5 

1.7 

12.0 

10.0 

18.4 

1.5 

1.2 

1.3 


5 . 3 

0.06 

6.7 

5.3 
0.6 

3.8 


9.16 

5.3 
3 .  .3 
7.7 
0  1 


16.4 


(jraiiis. 

0.7 

11.5 

12.8 

0.9 

9.7 

18.6 

12.6 

16.8 

9.4 

8.5 

23.7 

3.0 


3.0 


4.2 
6.0 
4.2 


8  8 
5.1 


4.1 

'3^8' 


Calories. 


20.9 
181.9 

98.1 

25.0 
100.6 
203.8 
182.6 
185.0 
106.4 

94.3 
444.7 

55.4 


87.7 

61.1 

143.1 

300.8 

406.3 

89.2 

255.6 

367.24 

156.8 

242.9 

.357.1 

149.4 

134 . 1 

148.3 

182.8 

255.7 

47.4 

126.0 

157.3 

264.6 

68.1 

55.9 

59.2 


76.8 
15.7 
75.12 

76.8 
10.9 
.35.5 


116.2 

76.8 
58.6 
72.0 
18.6 


7.9        342.0 


DIET    LISTS 


857 


("usfomary 
Measure 


Food. 


h  C. 


1  c. 


he. 

1 
1 

Ic. 


Custard 


Milk. 


Egg  Preparations 
(Continued) 
\  C.  milk. .  .  . 

*egg 

1  tbsp.  sugar. 

Total 


i  medium. 


1  piece. 

*c. 

6  tbsp. 
*c. 

I  tksp. 
1  tbsp. 


1  .slice. 

1 

he. 
he. 
h  c. 

1  tbsp. 

1  c. 

1  tb.sp. 

1  c. 

I  tbsp. 

I  c. 

1  tbsp. 

1  r. 

1  iiicli  ciiIk' 


Vegetables. 

Baked  beans 

Potato  (mashed) 

(unbaked)  140 

Potato  (baked) 

Potato  (boiled) 

Potato  chips 

Lima  beans 

Green  peas 

Corn 

Tomatoes 

String  beans 

Rice 

R.  D.  C. 

Rice  and  cheese 

Macaroni 

R.  D.  C. 

Macaroni  and  cheese 

Sweet  potato  (176  g.  before 
baking) 

Desserts. 

Shortcake 

Cake 

Berries . 

Whipped  cream 

Cornstarch  pudding 

Milk 

Cornstarch 

Sugar 

Rice  pudding 

Rice 

Milk 

Sugar 

(5   qt.)   ice   cream   (liome- 

made) 

Baked  apple 

Bavarian  cream 

Orange  sponge 

Lemon  jelly 

Mvicellniieous. 

Mayonnaise . 

Mayonnaise. 

.Maple  sirup 

Maple  .siruj) 

Moias.ses 

.Molasses 

('ream,  thin 

Cream,  thin 

Chee-se 


NuTRiKNTS  Yielded 


Weight. 


Calories 


Prot       I      J'at.       i     C    H 


Grams 

122.5 

25.0 

13.  S 


245.0 

153.0 
99.0 

105.0 

91.0 

28.0 

74.0 

62.0 

100.5 

128.0 

110.9 

99.0 

85.0 
79.0 

79.0 

129.0 

184.0 
69.0 
73.0 
42.0 
95.0 

183.8 

5.7 

13.8 

142.0 
32.6 

160.7 
10.9 

70.0 
120.0 
116.0 
109.0 

95.0 

19.0 
305.0 

21.0 
311.0 

19.0 
331.0 

14.0 
224.0 

17.0 


Grams. 
4.0 
3.4 


0 


7.4 
8.1 

10.6 
2.6 

3.1 

2.3 

2.0 

3 

2 

2 

1 

1 


12.5 
2.4 


3.9 

8.2 
6.4 
0.7 
1.1 
6.0 
6  0 


7.8 
2.6 
5.3 


2.1 

0.7 

3.84 

3.3 

1.6 

0.3 
4.2 


0 . 5 
10.0 
0.4 
5.6 
4 . 9 


Grams 
4.9 

2.7 


7.5 
9.8 

3.8 
3.0 

0.1 
0.1 
11.1 
0.2 
0.1 
1.2 
0.2 
0.1 
0.1 

13.9 
1.2 

12.9 

2.7 


24 

16 

0 

7 

7 


Grams 
6.1 

13^8 


6.5 
0.1 
6.4 


10.5 
0.9 
6  3 
4.7 
0.001 

15.6 

24S.9 


2.6 

41.4 

6.1 


19.9 
12.3 

30.0 
17.6 

25.8 

19.0 

13.1 

10.8 

6  1 

19.1 

5.1 

4.2 

24.2 

38.5 
25.5 

22.6 

54.3 

43.8 

36.3 

5.4 

2.1 

28.2 

9.3 

5.1 

13.8 

44.7 

25  8 

8.0 

10.9 

11.4 

17.7 
26.6 
28.1 

0.1 

2.3 

15.0 

222.0 

13.2 

229.3 

0.6 

10.1 

0.05 


87.0 

38.4 

56.6 

182.0 

174.8 

201.8 
110.7 

119.4 
88.3 

165.1 
58.4 
35.0 

101.0 
29.9 
23.1 

111.6 

338.4 
72.3 

247.5 

263.7 

1472.0 

327.6 

28.7 

85.7 

209.1 

131.6 

20.9 

56.6 

276.2 

117.4 

114.1 

44.7 

153.0 

146!? 
166.3 
121.8 

146.7 
2314.1 

61.5 
910.2 

56.2 
981.2 

28.3 
449.4 

77.0 


BIBLIOGRAPHY 


BIBLIOGRAPHY 

The  following  contains  a  selected  list  of  works  on  tuberculosis  to  which,  in 
part,  reference  has  been  made  in  the  text.  In  arrangement  and  abbreviations  the 
standard  of  the  Surgeons  General  Library  has  been  followed  throughout.  The 
references  in  the  Bibliography  are  to  be  found  according  to  subject  in  the  general 
index,  where  the  figures  in  black  type  indicate  the  serial  numbers  of  the  references 
in  the  Bibliography. 


Aberdeen  (Countess  of),  1909.  (1)  The 
campaign  against  tub.  in  Ire- 
land. Brit.  J.  Tuberculosi.s, 
Lond.,  iii,  3. 

Adami    (J.    G.),    1904.     (2)   On   facts, 
half  truths  and  the  truth,  with   i 
special  reference  to  the  subject 
of  tub.     Maryland  M.  J.,  Bait., 
xlvii,  117. 

Adams  (S.  H.),  1906.  (3)  Tub.  nos- 
trums. Nat.  Ass.  Study  &  Pre- 
vent. Tuberculosis.  Trans.,  N. 
Y.,  ii,  72. 

Adams  (S.  S.),  1907.  (4)  Are  tubercu- 
lous infants  and  children  in  the 
first  five  years  of  life  liable  to  be 
sources  of  infection?  Nat.  Ass. 
Study  &  Prevent.  Tuberculosis. 
Trans.,  N.  Y.,  iii,  320. 

Adler  (J.  E.),  1909.  (5)  Tub.  of  the 
skin,  with  visceral  tuberculous 
lesions.  Brit.  J.  Tuberculosis, 
Lond.,  iii,  41. 

Alison  (S.  S.),  1861.  (6)  Physical  ex- 
amination of  the  chest  in  pulm. 
consumption,  etc.      Lond. 

Allen  (A.  H.),  1907.  A.  (7)  Phagocy- 
tosis, etc.,  in  sputum,  as  a 
measure  of  resistance  in  tub. 
N.  York  M.  J.,  Ixxxvi,  102. 
Also:  Nat.  Ass.  Stvuly  & 
Prevent.  Tuberculosis,  Trans., 
N.  Y.,  iii,  217. 
B.  (8)  Homologous  bacteria  as  a 
vaccine    in    tub.  Nat.    Ass 

Study  &  Prevent.  Tuberculosis, 
Trans.,  N.  Y.,  iii,  2.50. 

Amrein  (O.),  1909.  (9)  Periostitis  et 
Adipositis  multiplex  tub.  toxica, 
behandelt  mit  Serum  Marmorek. 
Deutsche  med.  VVchnschr.,  xx.xv, 
251. 


Anders  (H.),  1907.  (10)  Physical  Diag- 
nosis, with  case  examples  of  the 
inductive  method.  N.  Y.  & 
Lond.,  D.  Appleton  &  Co., 
47.5  p.  80. 

Anders  (J.  M.),  1900.  (11)  The  value 
of  the  tuberculin  test  in  the 
diagnosis  of  pul,m.  tub.  Tr.  Am. 
Climat.  Ass.,  xvi,  89. 

1907.  (12)  Hemoptysis  due  to  tu- 
berculosis. J.  Am.  M.  Ass., 
Chicago,  xlix,  1067. 

Andre  (Ch.),  1908.  (13)  Flies  as 
agents  in  the  dissemination  of 
Koch's  bacillus.  Tr.  Internat. 
Cong.  Tuberc,  Washington. 

Andvord  (K.  F.),  1908.  (14)  Ueber  die 
Tub.-Immunitiit.  Tuberculosis 
Berl.,  vii,  397.  Also:  Norsk. 
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Vaughan  (V.  C.)  and  Wheeler  (S.  M.), 
1907.  (99G)  Split  products  of 
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Ass.  Study  &  Prevent.  Tuber- 
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Velden  (F.  von  den),  1909.  (997)  Die 
Verteilung  der  todlichen  Krank- 
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Miinchen.  med.  Wchnschr.,  hi, 
520. 

Vernet  (O.),  1907.  (998)  Un  cas  de 
meningite  tuberculeuse  traite 
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Rom.,  Geneve,  vii,  562. 

Viault  (F.),  1890.  (999)  Sur  I'aug- 
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Compt.  rend.  Acad.  d.  sc.  Par., 
cxii,  295. 

1892.  (1002)  Action  physiologique 
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cxiv,  1.562. 

Vierordt  (O.),  1889.     (1003)   Diagnosis 

innerer  Krankheiten.     Loipz. 
Villemin  (I.  A.),  1865.      (1004)  Cause 

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Gaz.  hebd.,  de  med..  Par.,  2  s., 

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Virchow  (R.),  1891.     (1005)  Ueber  die 

Wirkung  d.  Koch'schen  Mittels 

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1891-3.       (1006)    Demonstration    z. 

Koch'schen  Heilvcrfaliren   (Berl. 

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Waldenburg  (L,),  1869.        (1007)  Die 
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origin,  growth  and  administra- 
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Walker  (J.  R.),  1906.  (1011)  Tub. 
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900 


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INDEX 


INDEX 

Note:  The  figures  in  black  type  in  the  Index  indicate  the  serial  numbers 
of  the  Bibliography  under  which  the  references  ma}'  be  found. 


Acclimatization,  physiology  of,  676. 
"Acid-fast"  bacilh,    19. 

differentiation  of,  from  tubercle  bacilli, 

18,  20. 
isolation  of,  by  Moeller,  19. 
occurrence  of,  19. 
"Acid-fast"  bacteria,  566. 
Act  to  provide  for  reports  and  registra- 
tion of  tuberculosis  cases,  811- 
812. 
Acute  caseous  pneumonia,  I'A. 
Acute    miliary    tuberculosis,    631,    871, 

1053. 
Acute  tuberculous  pneumonia,  738. 
Acute  ulcerative  lobular  phthisis,  154. 
age  periods  at  which  most  common,  154. 
diseases  followed  by,  154. 
Adenotherapy,  48. 
Adirondack  Mountains,  701. 
Administrative    control    of    tuberculosis 

campaign,  497. 
Adrenalin  in  hemorrhage,  63-3. 
Advice  and  care  stations,  438-439. 
Africa,  advantages  of,  for  health  resorts, 

719. 
Age,  influence  of,  on  resistance  toward 

tuberculosis,  81. 
Age  and  disease,  997. 
Agglutinins,  96. 

Agnes  Memorial  Sanatorium,  652,  653. 
Agricultural  and  horticultural  colonies, 

447. 
Aiken,  S.  C,  704. 

Air,  density  of,  in  high  altitudes,  673. 
Air  and  environment,  608-612. 
in  city  life,  608. 
in  home  life,  610. 
cuspidors  in,  610. 
daily  routine  in,  611. 
59 


Air  and  environment  in  home  life,  floors 
in,  610. 
rooms  in,  610. 
in  tent  life,  609. 
Air  passages  in  tuberculosis,  66,  155,  200. 
Air  pressure  in  high  altitudes,  673. 
Albuquerque,  N.  Mex.,  710. 
Alcohol,  604. 

in  treatment  of  tuberculosis,  578. 
"Allergy"  in  tuberculosis  in  childhood, 

143-144. 
Almshouses,  asylums,   etc.,   care  of  the 

tuberculous  in,  465. 
Alteratives,  825. 

Altitudes,  high.     Sec  High  Altitudes. 
American  work  on  tuberculosis,  9. 
Anal  fistula^,  treatment  of,  768-770. 
operative,  768. 

contraindications  for,  768,  769. 
method  of,  769. 
tuberculous,  766. 
Anemia,  formulary  for,  825. 
treatment  of,  620. 
arsenic  in,  621. 
hypopho.sphites  in,  621. 
iron  in,  621. 
strychnin  in,  621. 
Ancrgy  in  tuberculosis  of  childhood,  146. 
-Vnimal    and    human   tubercidosis,    814, 

816,  879. 
Anodynes,  821. 
Anorexia,  175,  294. 
.Vnorexia  and  emaciation,  formulary  for, 

825. 
.\ntagonistic   bacteria    in    treatment    of 
tuberculosis,  565-568. 
"acid-fa.st"  bacteria,  566. 
attenuated  tubercle  bacilli,  566. 
bacterium  termo,  565. 
905 


906 


INDEX 


Antagonistic  bacteria  in  the  treatment 
of  tuberculosis,  erysipelas,  565. 
products  of  tubercle  bacillus,  567. 
syphilis,  565. 
vaccination,  567. 
yeast,  567. 
Antiphthisin,  516. 
Antistreptococcic  serum,  575. 
Antitoxins,  96. 
Antituberculin,  97. 

Antituberculosis  associations,  local,  413. 
Antituberculous    work    among    factory 

workers,  492. 
Apices    of    lungs,    percussion     of,    2137, 

238. 
Apices  of  lungs  in  tuberculosis,  394,  395, 

396,  593,  594,  689,  690,  867. 
Appalachian  health  resorts,  703. 
Appetite  and  weight  in  tuberculosis,  loss 
of,  619. 
cod-liver  oil  in,  620. 
liquid  food  in,  620. 
olive  oil  in,  620. 
Arizona  health  resorts,  713. 
Arrested  tuberculosis,  397. 
Arsenic  and  its  derivatives  in  treatment 

of  tuberculosis,  577. 
Arsenic  in  anemia,  621. 
Arterioles  of  bones,  tuberculosis  in,  732. 
Arthrectomy,  742. 
Arthritis,  tuberculous  suppurative,  737, 

738. 
Asheville,  N.  C.  704. 
Atlanta,  Ga.,  705. 
Attenuated  tubercle  bacilli,  566. 
Autopsies,  in  children,  tuberculosis  sta- 
tistics from,  108-110. 
tuberculosis     statistics     taken     from, 
105-108. 
recent,  106. 
Avian  and  mammalian  tuberculosis,  804. 
Avian  tuberculosis,  14. 
organs  affected  by,  14. 

Bacillen  emulsion  (B.  E.),  516. 
Bacteria,  "acid-fast,"  566. 
Bacteriology,  8,  16,  17,  19,  20,  26,  27,  29, 

353,    435,    495,    564,    578,    949, 

966. 
Bacteriology  of  the  blood,  291. 
Bacterium  termo,  565. 


Barometric  pressure,   physiologic  influ- 
ence of,  674. 
high,  674. 
low,  674. 
Barrel-shaped  chest,  226. 
Beraneck's  tuberculin,  516. 
Bismuth  subnitrate,  toxic  effects  of,  64. 
Bladder,  tuberculosis  of,  791. 

symptoms  of,  791. 
Blood  cells  as  therapeutic  agent,  570. 
Blood  changes  in  tuberculosis,  285.     See 

also  under  Objective  Signs. 
Blood  in  high  altitudes,  674,  675. 
Blood  in  tuberculin  treatment,  551. 
Blue  Ridge  Mountain  resorts,  703. 
Bones,  tuberculosis  of,  731. 
in  arterioles,  732. 

degeneration  of  tissue  in,  732. 
in  venous  terminals,  732. 
"cold  abscess"  in,  733. 
degeneration  of  tissue  in,  733. 
vascular  conditions  in,  732. 
special,  733. 

of  cranial  vault,  733. 
of  ribs,  734. 
of  sternum,  734. 
of  vertebrae,  734. 
tubercle  bacilli  in,  731. 
Bovine    and    human    tuberculosis,    228, 
241,    254,    298,    299,    352,    730. 
795,  812.  813,  824,  854. 
Bovine  bacillus,  shape  and  size  of,  15. 

staining  of,  15. 
Bovine  tuberculosis,  180,  241,  270,  301, 
414     415,    454,    505.    786.    812, 
813,  879,  912,  921,  994, 
Bovine  tuberculosis,  14. 
characteristics  of,  14. 
differentiation  of.  from  human  tuber- 
culosis, 14. 
heredity  in,  34. 

relation  of,  to  human  health,  .32,  35, 
44. 
Brain,  tuberculosis  of,  754. 
"Brehmer  Rest,"  446. 
Bronchopneumonia,  tuberculous,  72. 
Bronchopneumonia  in  ulcerative  tuber- 
culosis, 75. 
Broth  filtrate  (B.  F.),  516. 
Bunge  and  Trantenroth  method  of  stain- 
ing tubercle  bacillus,  19. 


INDEX 


907 


Calcium    in    treatment    of    tuberculosis, 

582. 
California,    advantages    of,    for    health 

resorts,  714. 
Canada,  advantages  of,  for  health  resorts, 

718. 
Canary  Islands,  as  health  resort,  718. 
Capsules  of  Schron,  1.5. 
shape  and  size  of,  15. 
staining  of,  15. 
Carbohydrates,  605. 
Cardiac    displacement    in    tuberculosis, 

285. 
Cardiac  weakness  and  dyspnea,  634-635. 
Carpus  and  tarsus,  tuberculosis  of,  743. 
Caseation,  55,  56. 

cause  of  coagulation  in,  57. 
character  of,  56. 
"fibrinoid"  in,  58. 
of  tuberculous  exudates,  58. 
process  of,  58. 
Caseous  foci,  calcification  of,  58. 

bacilli  in,  59. 
Caseous  material,  autolytic  enzymes  de- 
stroyed in,  ,'^8. 
composition  of,  57-58. 
fat  in,  57. 
proteid  in,  57. 
Castration,  783. 

Catarrhal  inflammations  and  their  treat- 
ment, 625. 
by  applications,  625. 
by  inhalers,  625. 
Character  of  tuberculosis,  500. 
Chemical   aspects   of   tuberculosis,    204, 
219,    220,    419,    696,    697,    704, 
745,    746,    747,    748,    833,    995, 
1047. 
Chest,  form  of,   in  pulmonary  tubercu- 
losis, 224. 
Chest    diagrams    in    recording    findings, 

365-374. 
Children,   seaside   and   inland   sanatoria 

for,  439. 
Children,  tuberculosis  in,  4,  59,  82,  111, 
123,  124,  197,  211,  247,  286, 
303,  304,  306,  322,  323,  362, 
370,  372,  381,  385,  389,  683, 
684,  709,  784,  835.  863,  864, 
885,  886,  912,  913,  917,  1058, 
1072. 


Children,  tuberculosis  in,  141-148. 

acute,  following  measles  and  whoop- 
ing cough,  89. 
"allergy"  to  tuberculin  in,  143-144. 
anergy  in,  146. 
diseases  predisposing  to,  146. 
general  miliary,  145. 

dissemination  of  tubercles  in,  145. 
hypergy  in,  147. 

infection  of  lungs  result  of  rupture 
of  foci  in  bronchial  nodes  in,  61. 
latency  of  bacilli  in,  87. 
latency  of  bacilli  in  lymph  nodes  in, 

60. 
latent,  112. 

immunity  produced  by,  112. 
lymph  gland,  clinical  stages  of,  143. 
primary  stage  of,  143. 
progression  of  infection  in,  144. 
breaking  through  of  lymphatic 
system  in,  145. 
swelling  of  lymph  glands  in,  143. 
tuberculin  reactioh  in  ("allergy"), 
143-144. 
lymph  nodes  most  frequent  points  of 

primary  locahzation  in,  61. 
meningeal  and  lymphatic,  following 

exanthematous  diseases,  89. 
portals  of  entry  for  infection  in,  142. 
through  lungs,  142. 
through  other  portals,  143. 
prophylaxis   and   therapy   of,    147- 

148. 
scrofulosis  in,  147. 
prognosis  of,  147. 
tyi^es  of,  147. 
scrofulous,  following  tonsilitis,  diph- 
theria, and  influenza,  89. 
secondary  invasion  of  lymph  nodes 

in,  63. 
statistics  of,   from   autopsies,    108- 
110. 
in  early  childhood,  109. 
percentage  of  tuberculous  findings 
in,  109. 
increase  in,  with  advancing  age, 

109. 
variations  in,  109. 
susceptibility  to,  87. 
von  Behring's  three  hypotheses  of  in- 
gestion of  tubercle  bacilli  in,  87. 


908 


INDEX 


Children's  school  farms,  498. 
Chills,  169. 

Cinnamic  acid  in  treatment  of  tubercu- 
losis, 580. 
Climate  and  individual,  683. 
Climate  and  social  conditions,  68.3. 
Climate,  choice  of,  667. 
classification  of,  666. 
dry,  667. 

contrasted  with  moist,  667. 
effect  of  excessive  illumination  in,  670. 
factors  in  choice  of,  in  treatment  of  the 
tuberculous,  690. 
atmospheric  conditions,  690. 
economic  circumstances  of  patient, 

691. 
general  topography,  690. 
psychic  condition  of  patient,  691. 
social  environment,  690. 
inland,  686. 

of  desert,  688.   . 

indications  for,  689. 
of  high  altitude,  687. 

contraindications  for,  688. 
effect  of,  on  the  blood,  687. 
indications  for,  688. 
jihysiologic  effects  of,  687. 
of  low  altitude,  687. 
of  medium  altitude,  687. 
ocean,  684. 
on  coast,  686. 
on  islands,  685. 
on  sea  voyages,  685. 
physiologic  jiroperties  of,  685. 
physiology  of,  663. 
producing  highest  machine  efficiency 

of  body,  669,  678. 
relation  of,  to  physical  and  psychical 

condition,  663. 
specific,    for   pulmonary   tulxTCulosis, 
682. 
selection  of,  696. 
types  of,  684. 
Climatic  treatment,  663,  680. 

comparison  between  closed  and  open 

resorts  in,  695. 
comparison  of  results  of,  in  tuberculo- 
sis, 689. 
general  utilization  of,  690. 
historical  aspects  of,  680-682. 
in  closed  resorts,  692. 


Climatic  treatment  in  home  or  near-by 
resorts,  693. 
in  open  resorts,  692. 

abode  of  patient  in,  694. 
advantages  of,  694. 
in  sanatoria,  692. 
Climatology,  77,  93,  123,  124,  127,  137, 
165,    166,    170,    183,    184,    279, 
280,    284,    293,    307,    349,    368, 
388,    391,    398,    406,    407,    420, 
421,    434,    487,    506,    538,    576, 
635,    667,    695,    775,    903,    906, 
907,  930,  999,  1001,  1002,  1040, 
1043,  1064,  1073,  1083. 
Climatology,  aims  of,  670. 
medicinal,  ideal  of,  670. 

meteorologic  factors  in,  067. 
humidity,  667. 
temperature,  667. 
Climatotherapy,  flefinition  of,  682.     See 

also  Climatic  Treatment. 
Climatotherapy  and  the  individual,  683. 
Clinic,  tuberculosis,  434. 
Clinical  examination,  876. 
Chnical  nomenclature,  113,  114,  115,  116. 
Closed  resorts,  695. 

climatic  treatment  in,  692. 
Clothing  in  tuberculosis,  616. 
Clubbed  fingers,  193. 
Cod-liver  oil  in  tuberculosis,  620. 
"Cold  absce.ss,"  733. 
Cold-blooded    animals,    tuberculosis    in, 

344,  598. 
Colonies,  agricultural  and  horticultural, 

447. 
Colorado  health  resorts,  707. 
Colorado  Springs,  709. 
Comparative  study  of  various  forms  of 

tuberculosis,  817. 

Complications  of  tuberculosis,   127,  668, 

727,    732,    735,    755,    788,    791, 

803,  836,  950,  961,   1020,  1022. 

Compulsory    examination     of    children, 

496. 
Compulsory  notification  of  tuberculosis 
cases,  447. 
an  act  for,  SI  1-812. 
Compulsory  registration  of  tuberculous 
cases  in  the  United  States,  458- 
463. 
an  act  for,  811-812. 


INDEX 


909 


Compulsory  reports  and  registration  of 
tuberculosis  cases,  45,  85,  274. 
Constipation,  formulary  for,  823. 
Constricting    rubber    bands    in    hemor- 
rhage, 634. 
"Consumption   cures,"  protest   against, 

416. 
Contusion  of  lung,  759. 
Cough,  causes  of,  624,  62.5. 

discipline  of,  in  tuberculosis,  4U6. 
formidas  to  combat,  820. 
ti'eatment  of,  624. 

excessive  secretion  in,  (i27-628. 
insistent  ami  rasping,  027. 
tight,  627. 
Cough  mixtures,  82(J. 
Country  life  as  a  means  of  prevent i<jn  of 

tuberculosis,  47U. 
Course  of  tuberculosis,  727,  895,  1060. 
"Cracked-pot"  resonance,  243,  24.'). 
Cranial  vault,  tuberculosis  of,  733. 
Creosote  and  its  derivatives  in  treatment 

of  tuberculosis,  ,576. 
Creosote  in  gastro-intestinal  disturbances, 

630. 
Cultures,  495. 

Cultures  of  pseudo-tubercle  bacillus,  20. 
Cultures  of  tubercle  bacillus,,  acid  jjotas- 
sium  phosphate  in,  22. 
homogeneous,  22-23. 
human,  Hesse's  method  of  i-solation  of, 
22. 
Theobald  Smith's  method  of,  21. 
obtaining  of,  21. 
various  media  for,  21. 
Cuspidors,  610. 

Cutaneous  reaction,  236,  271,  283,  707. 
Cutaneous  reaction,  382. 
Cyanosis,  178. 
Cytodiagno.sis  in  tuberculosis,  3.50. 

Daily  routine  of  patient,  611. 
Darkness,  effect  of,  on  tubercle  bacillus, 

2.5. 
Dark-skinned  races  of  America,  predis- 
position of,  to  tuberculosis,"  120. 

tuberculosis  among,  118-120. 
Day  camps,  440. 

ferryboat,  441. 
Day  and  night  camps,  497. 
Debility,  treatment  of,  618. 


Decolorizing  agents,  13. 

Deming,  N.  Mex.,  711. 

Density  of  air  in  high  altitudes,  673. 

Denver,  Colo.,  708. 

Desert  climate,  688. 

Destructive  agents  of  tubercle  bacillus, 

24. 
Diagnosis  of  tuljerculosis,  10,  11,  33,  34, 
38,  46,  65,  91,  95,  139,  146,  156, 
164,    176,    192,    205,    207,    210, 
216,    231,    232,    233,    234,    236, 
238,    248,    253,    259,    285.    303, 
304,    345,    369,    373,    381,    383, 
386,    406,    427,    428,    447.    452, 
461.    466,    472,    473,    474,    475, 
486,    493,    507,    531.    539,    572, 
573,    589,    590,    593,    594,    619, 
623,    625,    633,    687,    689,    690, 
752,    753,    767,    771,    793,    843, 
881,    949,     1003. 
Diagnosis  of  tuberculosis,  325,  380. 
agglutination  serum  reaction  in,  349. 
cytodiagnosis  in,  3.50. 
heated  serum  reaction  in,  352. 
history  in,  330. 
childhood,  331. 
family,  331. 
of  habits,  331. 
personal,  .331. 
present,  331. 
status  prwsens  in,  .331. 
mctaboli.sm  in,  380. 
ophthalmic  reaction,  346,  380. 
opsonic  index  in,  350. 
fluctuating,  352. 
high,  351. 
low,  351. 
normal,  351. 
sputum  examination  in,  327. 
by  animal  inoculations,  330. 
by  microscope,  327. 
symptoms  and  clinical  course  in,  335. 
anorexia  in,  336. 
chills  in,  3.36. 

circulation  of  blood  in,  337. 
cough  in,  338. 
cyanosis  in,  336. 
dyspnea  in,  337. 
emaciation  in,  337. 
expectoration  in,  338. 
fever  in,  335. 


910 


INDEX 


Diagnosis  of  tuberculosis,  symptoms  and 
clinical  course  in,  hemorrhage 
in,  338. 
hoarseness  in,  337. 
languor  in,  336. 
nose  and  throat  in,  338. 
pain  in,  337. 
sweats  in,  337. 
period  of  observation  in,  326. 
physical  signs  in,  331. 
auscultation  in,  333. 
breath  changes  in,  333. 
fluoroscopy  in,  335. 
inspection  in,  332. 
laryngeal  examination  in,  335. 
menstruation  in,  333. 
palpation  in,  332. 
percussion  in,  333. 
rales  in,  334. 
tuberculin  test  in,  339. 
contraindications  for,  346. 
dosage  in,  342. 
modifications  of,  346. 

conjunctival  reaction,  346. 
advantages  of,  348. 
contraindications  for,  348. 
cutaneous  reaction,  346. 
reaction  in,  343. 
sites  of  injection  for,  342. 
technic  of,  341. 
time  of  injection  of,  343. 
Diagnostic    measures    other    than   reac- 
tions, 384. 
Diagnostic  tests  for  tuberculosis,  33,  34, 
38,  177,  192,  198,  238,  259,  271, 
292,    386,    412,    427,    452,    461, 
472,    473,    474,    475,    478,    573, 
623,    625,    657,    658,    706,    707, 
718,    740,    782,    850,    851,    857, 
898,  902,  926,  1052,  1057,  1071, 
1081. 
Diagnostic  value  of  reactions  in  tuber- 
culosis, 380. 
Diarrhea,  formulary  for,  824. 
Diet,  102,  303,  469. 
Diet  lists,  853-857. 
Dietaries,  605-607. 
Differential    diagnosis    in    tuberculosis, 

637. 
Differential    diagnosis    of    tuberculosis, 
353. 


Differential  diagnosis  of  tuberculosis  from 
actinomycosis,  356. 
acute  bronchitis,  354. 
asthma,  354. 
bronchiectasis,  355. 
chronic  pneumonia,  354. 
echinococcus  cyst  of  lung,  356. 
fungous  infection  of  lung,  357. 
heart  lesions,  359. 
lobar  pneumonia,  354. 
malaria,  359. 

malignant  disease  of  lungs,  358. 
pleurisy,  355. 
pneumothorax,  356. 
pulmonary  sj^Dhilis,  357. 
typhoid  fever,  360. 
Diffused  light,  action  of,  on  tubercle  bacil- 
lus, 49. 
Digestive  system  in  tuberculosis,  318. 
Digestive  tract,  infection  by,  182. 
Digestive  tract,  vaccination  by,  180,  182. 
Discharged  cases  of  tuberculosis,  135. 
Disinfectants,  formulary  for,  829. 
Disinfection  in  tuberculosis,  406. 
Disinfection  of  sputum  containing  tuber- 
cle bacillus,  25. 
Dispensaries,  371,  511,  517,  557. 
Dispensaries,  special,  496. 
Dissemination    of    tubercle    bacillus   by 
flies,  49. 
by  way  of  mucous  and  serous  mem- 
branes, 64. 
from  sputum,  32. 
in    urinary    tract    from     tuberculous 

kidney,  64. 
rapid,  cause  of  acute  miliary  tubercu- 
losis, 64. 
of    acute    tuberculosis    of    serous 

membranes,  64. 
of  acute  tuberculous  pneumonia, 
64. 
to   digestive   tract   by   swallowing   of 

sputum,  64. 
to  outside  of  body  through  routes  of 

secretion  and  excretion,  64. 
within  infected  body,  62. 
by  lymph  vessels,  62. 
Domestic  animals,  prophylactic  measures 

against  tuberculosis  in,  473. 
Dorset's  method  of  isolation  of  tubercle 
bacillus,  21-22. 


INDEX 


911 


Dry  air,  danger  from,  486. 
Dry  climate,  contrasted  with  moist,  667. 
Dullness  in  percussion  of  tuberculosis,  239. 
Duty  of  consumpti\e  to  society,  408. 
Duty  of  municipality  toward  family  of 

consumptive,  446. 
Duty  of  society  toward  the  consumptive, 

408. 
Duty  regarding  tuberculosis,  521. 
Duty  to  consumptive,  514. 
Dyspnea,  176. 

Economic  loss  to  Commonwealth  through 

tuberculosis,  414. 
Economic  meaning  of  tuberculosis,  495. 
Eggs  in  diet  of  tuberculosis,  603. 
Ehrlich's  anilin  water,  16. 
Emaciation,  173. 
Emphysema  in   tuberculosis,   245,   262, 

281. 
Environment,  257. 
Environment,  social,  690. 
Eosinophiles,  156. 
Epididymectomy,  782. 
Epitheloid,  53. 

Erysipelas  and  tuberculosis,  928. 
Erysipelas  in  tuberculosis,  565. 
Etiology  of  tuberculosis,   30,    126,    168, 

229,    242,    433,    636,    812,    820, 

946,    956,    1004. 
European  health  resorts,  718. 
Excretions,  care  of,  in  tuberculosis,  408. 
Exercise  in  tuberculosis,  613. 
graded  system  of,  613. 

tests  for  discharge  by,  615. 
pulmonary  gymnastics  in,  613. 
untoward  results  of,  616. 
walking  in,  613. 
Exhibit,  itinerant,  tuberculosis,  of  Ken- 
sington, 431. 
open-air,  of  Dr.  Oscar  H.  Rogers,  429- 

430. 
tuberculosis,  held  in  New  York  City, 

1908,  426-429. 
Exhibits,  tuberculosis,  425-433. 
Experimental  work  in  tuberculosis.  252, 

504,  970,  972,  976,  982. 

"False  specifics,"  575-585. 
alcohol,  578. 
arsenic  and  its  derivatives,  579. 


"False  specifics,"  calcium,  582. 
creosote  and  its  derivatives,  577. 
ichthyol,  581. 
inhalations,  583. 
injections,  584. 
iodin,  581. 
lecithin,  582. 

leucocytosis-producing  drugs,  579. 
cinnamic  acid,  580. 
nucleic  acid,  580. 
silver,  582. 
sprays,  584. 
strychnin,  583. 
Family  physician,  522,  560, 
Fat  in  diet  of  tuberculosis,  605. 
Federal  employees,  tuberculous,  care  of, 

463. 
Federal  phthisiophobia,  418. 

results  of,  422. 
Ferryboat  day  camp,  441. 
Fever,  formulary  for,  826. 
in  tuberculosis,  335. 
treatment  of,  622. 

hydrotherapy  in,  623. 
medicines  in,  622. 
rest  and  food  in,  622. 
Fibroid  tuberculosis  of  the  lungs,  78. 
Flagstaff,  Ariz.,  713. 
Florida  health  resorts,  706. 
Fluoroscopy,  268. 
Food  in  tuberculosis,  601. 
alcohol,  604. 

appetizing  and  bitter  tonics,  607. 
carbohydrates,  605. 
dietaries,  605-607. 
eggs,  603. 
fat,  605. 
meat,  604. 
milk,  603. 

prepared  foods,  608. 
weight  gained  by,  602. 
Food  values,  602. 

Formulary  for  symptomatic  treatment  of 
tuberculosis,  819-831. 
anodynes  in,  821. 

for  acute  pleuritic  pains  with  fever, 

821.  ' 

for  local  use,  821. 
disinfectants  in,  829. 

bichlorid  of  mercury,  829. 
chlorid  of  lime,  829. 


912 


INDEX 


Formulary  for  symptomatic  treatment 
of  tuberculosis,  disinfectants  in, 
quicklime,  830. 
for  laryngeal  tuberculosis,  827. 
for  internal  use,  82'J. 
for  local  use,  827. 
to  combat  anemia,  825. 
alteratives,  825. 
nutritives,  826. 
to  combat  anorexia  and  emaciation, 

825. 
to  combat  constipation,  823. 
to  combat  cough,  820. 
cough  mixtures,  820. 
inhalation,  820. 
to  combat  tliarrhea,  824. 
to  combat  fever,  820. 
to  combat  heart  com[)lications,  822. 
for  tendency  to  heart  failure,  823. 
to  combat  hemoptysis,  822. 
to  combat  hyperidrosis,  822. 
to  combat  insomnia,  826. 
for  internal  use,  828. 
for  local  use,  827. 
to  combat  other  digestive  disturbances, 
824. 
Frequency  of  tuberculosis,  70,  168    389, 

720. 
Frequency  of  tuberculosis,  105-117. 
among     the     dark-skinned     races     of 

America,  118-130. 
as  regards   geographic   location,    116- 

117. 
autopsy  statistics  in,  105-108. 
ages  of  distribution,  107,  108. 
by  Burkhardt,  107,  108, 

age  groups  of  distribution,    107, 

108. 
percentages   of   tuberculous   find- 
ings, 107,  108. 
by  Nageli,  106. 
difficulty  in  obtaining,  105. 
in    children,    108-110.  vSee    also 

Tuberculosis  in  Children, 
in  hospitals,  106. 

error  in,  106. 
recent,  l06. 
in  insane  asylums,  131-138. 
iritra  vitum,  comparison  of  tuberculin 
findings    with    autopsy    statis- 
tics, 110,  112. 


Frequency  of  tuberculosis,  intra  vitum, 
in  adults,  110. 
in  childhood,  110-111. 

increase  of,  with  advancing  age, 
110. 
tuberculin  findings,  110-112. 
variations  in,  110. 
latent,  in  childhood,  112. 
mortality  statistics  of,  112,  ll;>-116. 
ages  at  which  most  frequent,   113, 

114. 
compared  with  those  of  jJneumonia, 

116. 
comparison  of,   at  giv(!n  ages  with 
population  at  those  ages,  114- 
116. 
Funnel-chest,  230. 

Gabbet's  method  of  staining,  16. 

"Galloping  consumption,"  154. 

Gastric  juice,  action  of,  on  the  tubercle 

bacillus,  37. 
Gastro-intestinal  disturbances,  629. 

creosote  in,  630. 
Gaylord  Farm  Sanatorium,  648,  651. 
General  miliary  tuberculosis  in  childhood, 
145. 
dissemination  of  tubercles  in,  145. 
Genital  tract  in  women,  tuberculosis  of, 
794. 
pathology  of,  794. 
symptoms  and  diagnosis  of,  794. 
treatment  of,  794. 
Genito-urinary  system,   tuberculosis   of, 
777. 
general  considerations  of,  777. 
Geograjjliic  distribution  of  tuberculosis, 

116-117. 
Goodall's  suggestions  to  teachers,  804- 

807. 
Goodsell-Bedell  Law,  420. 
Graded  system  of  exercise,  613. 
Granulation  tuberculeuse,  55. 
"Granulation  tuberculosis,"  55. 
"Grape  disease,"  14. 
"Great  White  Plague,"  285. 

Handbills  and  invitations  to  lectures,  414. 
Hardening  in  tuberculosis,  617. 
Healing  of  tuberculous  processes,  59. 
formation  of  connective  tissue  in,  59. 


INDEX 


913 


Healing  of  tuberculous  processes,  slaty 

indiu-ation  in,  59. 
Health  Department  of  New  York  City, 
work  of,   in  tuberculosis,  447- 
458. 
Health  resorts,  enumeration  of,  698. 
foreign,  717. 
Africa,  719. 
Canada,  718. 
Canary  Islands,  718. 
Egyi:)t,  719. 

southern,  719. 
Europe,  718. 

Alpine  region,  718. 

Russia,  719. 

southern  coast  of,  718. 

Southern  Spain,  719. 
Madeira,  718. 
Mexico,  717. 
United  States,  700. 

Adirondack  Mountains,  701. 

Saranac  Lake,  701. 

Trudeau,  701. 
Appalachians,  703. 

Aiken,  S.  C,  704. 

Asheville,  N.  C,  704. 

Atlanta,  Ga.,  705. 

Augusta,  Ga.,  705. 

Southern  Pines,  N.  C,  704. 

Thomasville,  Ga.,  706. 
Arizona,  713. 

Flagstaff,  713. 

Prescott,  713. 
Blue  Ridge  Mountains,  703. 
California,  714. 

Los  Angeles,  715. 

Pasadena,  716. 

San  Diego,  716. 

Santa  Barbara,  717. 

Southern,  715. 
Colorado,  707. 

Colorado  Springs,  709. 

Denver,  708. 
Florida,  706. 
New  England  States,  700. 

Maine,  700. 

New  Hampshire,  701. 
New  Jersey,  702. 

Lakewood,  702. 
New  Mexico,  710. 

Albuquerque,  710. 


Health    resorts,    ignited    States,    New 
Mexico,  Deming,  711. 
Santa  Fe,  710. 
Silver  City,  711. 
New  York,  702. 

Sea  Breeze,  702. 
Pennsylvania,  703. 
Rocky  Mountain  region,  707. 
Heart  complications,  formulary  for,  822. 
Heart  in  tuberculosis.  110,  144,  148,  149, 

442,  826,  836. 
Heart  strain  in  high  altitudes,  674. 
Hectic  flush,  192. 

Hematology.  15,  18,  92,  109,  157,  175, 
185,  217,  224,  289,  300,  356, 
361,  402,  426,  437,  480,  492, 
606,  624,  704,  822,  830,  839, 
860,  882,  920,  938,  945,  948, 
953,  958,  992,  999,  1000,  1001, 
1019,  1043,  1076. 
Hemoptysis,  141,  199,  346,  743,  923. 
Hemoptysis,  formulary  for,  822. 

in  repeated  doses  of  tuberculin,  555. 
Hemorrhage,  963. 
Hemorrhage  in  tuberculosis,  212,  338. 

treatment  of,  631. 
Hemorrhage    in    ulcerative    pulmonary 

tuberculo.sis,  75. 
Hemostasis,  920. 

Hemotherapy  in  treatment  of  tubercu- 
losis, 571. 
Hereditary  tuberculosis,  33. 
Heredity,    24,    188,    254,    322,    323,    468, 
875,    901,    915.    916,    918,    929, 
934,  993,  1028,  1078. 
Heredity,  influence  of,  on  resistance  to 
tuberculous  infection,  81. 
transmission  of  tuberculosis  by,  33. 
statistics,  33. 

through  placental  tuberculosis,  33. 
through   semen,  33. 
through  uterine  tuberculosis,  33. 
High  altitudes,  671-679,  687. 
blood  in,  674,  675. 
density  of  air  in,  673. 
effect  of,  upon  nervous  system,  672, 

677,  678. 
heart  strain  in,  674. 
physiologic  reactions  in,  672,  676. 
pressure  of  air  in,  673. 
vital  reactions  on  removal  to,  676. 


914 


INDEX 


Hip-joint,  tuberculosis  of,  744. 
diagnosis  of,  747. 
occurrence  of,  744. 
primary  synovial,  744. 
sequestra  in,  745. 
symptoms  of,  746. 

absorption  and  shortening  in,  746. 
friction  in,  746. 
limp  in,  747. 
pain  in,  746. 
treatment  of,  747. 
Hippocrates,  212. 
Histogenesis  of  tuberculosis,  62. 
Histology,  401,  416.  459,  611.  639,  640, 

646. 
History  of  tuberculosis,  30,  798,  971,  973. 
History  of  tuberculosis,  3. 
anatomical  factors  in,  5. 
etiological  factors  in,  6. 
prevention  in,  7. 
semeiology  in,  3. 
Hoarseness  in  tuberculosis,  171,  337. 
Home  treatment,  510,  545,  550  553,  562, 

620,  693,  731.  734,  741,  797. 
Home  treatment  by  sanatorium  methods, 

600. 
House  fly,  a  carrier  of  tuberculosis,  487. 
Housing  for  consumptives,  189,  212,  276. 
Housing  of  the  masses,  477. 
Humidity,  667. 
Hydrops,  737. 

Hydrotherapy  in  tuberculosis,  617,  623. 
Hygiene  of  the  tuberculous,  397. 
Hypergy   in   tuberculosis   of   childhood, 

147. 
Hyperidrosis,  formulary  for,  822. 
Hypophosphites,  621. 

Ichthyol    in    treatment  of    tuberculosis, 

581. 
Illumination,  excessive,  effect  of,  670. 
Immunity  to  tuberculosis,  14,  35.  37,  40, 

41.    51.    53,    55,    57,    181.    214. 

310,    468     502.    503,    714,    715, 

723.    724.    726,    760.    761.    837. 

853,    899,    970.    972,    975.    980. 

981.     983,     1034.     1036.     1037, 

1038. 
Immunity  to  tuberculosis,  93-96,   118- 

120. 
by  application  of  inoculation,  94. 


Immimity  to  tuberculosis  by  application 
of  inoculation  on  cattle,  94-95. 
chief  drawback  to,  95. 
by  introduction  of  bacilli  in  capsules 

within  system,  101. 
experiments  in,  93. 
by  "Rest"  bacilli,  94. 
by  T.  R.,  93. 

by  various  inoculating  agents,  94. 
in  inoculated  cattle,  of  limited  dura- 
tion, 101-102. 
mechanism  of,  95,  102. 
jjartial,    in    '"inherited"   tuberculosis, 

93. 
produced  by  latent  tuberculosis,  112. 
relative,  93. 

specific,  summary  of,  97. 
specific  substances  in  the  blood  in,  96. 
agglutinins  and  precipitins,  96. 
antitoxins,  96. 
antituberculin,  97. 
lysins,  97. 
opsonins,  96. 
Immvmization,    active,    during   infancy, 

397. 
Immunized  milk  for  infants,  396. 
Indian,  tuberculosis  in,  127-129. 
etiology  of,  127-129. 
statistics  on,  128. 
Individual  resistance  to  tuberculous  in- 
fection, 81. 
Infection  in  tuberculosis,  4,  52.  Ill,  118, 
215     278,    311.    503.    543,    800, 
820,    821,    823,    839,    854,    968. 
Infection  in    tuberculosis  by  digestive 

tract,  182. 
Infection,  exposure  of  lungs  to,  61. 
exposure  of  lymph  nodes  to,  61. 
respiratory,  44-45. 
sources  of,  31-32. 

bovine  tuberculosis,  32. 
from  sputum,  32. 

by  handkerchiefs,  .32. 

by  hands,  32. 

by  ki.ssing.  .32. 

distribution  and  suppression  of,  in 

air,  32. 
dry  and  pulverized,  32. 
in  droplets  from  the  mouth,  32. 
in  public  places,  32. 
in  streets,  32. 


INDEX 


915 


Infection  of  intestine  through  swallowing 
tuberculous  sputum,  38. 
susceptibility  of  lungs  to,  61. 
of  lymph  nodes  to,  61. 
Inflammation  of  lungs,  chronic,  866. 
Influenza  and  tuberculosis,  o'JU. 
Inhalations  in  treatment  of  tuberculosis, 

583. 
Inhaler,  zinc,  of  Robinson,  820. 
Injections  in  treatment  of  tuberculosis, 

584. 
Inland  climate,  686. 

Inoculation  treatment  in  mixed  and  con- 
comitant infections,  595. 
results  of,  597. 
Inoculation  tuberculosis,  395. 
Insane,  tuberculosis  in,  455,  764.  967. 
Insane,  tuberculosis  in,  131-138. 
diagnosis  of,  134. 
in  asylums,  mortality  in,  132. 

statistics  of,  131. 
in  hospitals,  133. 

difference  of  prevalence  in  the  two 

sexes,  134. 
employment  for,  134. 
etiology  of,  133. 
treatment  of,  135. 
individual,  135. 
by  camp  life,  137. 
in  sanatoria,  135. 
prevention,  135. 
tuberculous,  care  of,  463. 
Insane  asylums,   frequency  of  tubercu- 
losis in,  131-138. 
Insomnia,  formulary  for,  826. 
Insurance  against  tuberculosis,  493. 
Insurance  of  workmen  against  sickness. 

500. 

International  Congress  of   Tuberculosis, 

Washington,  54,  260,  266,  272, 

315.   316.   445,   549,   922. 

International  Congre.ss  of  Tuberculosis, 

1908,  resolutions  passed  by,  500. 

International   Congress   of  Tuberculosis 

at  Stockholm,  446. 
International  Congresses  of  Tuberculosis. 

of  1904  and  1905,  512. 
Intestinal  tuberculosis,  756. 
aerogenous,  757. 
autopsy  findings  in,  757-758. 
enterogenous,  757,  759. 


Intestinal  tuberculosis,  etiology  of,  761. 
hypertrophic  type,  762. 
ulcerative  type,  761,  762. 
frequency  of,  758. 
general  considerations  of,  756. 
location  of,  764. 
modes  of  infection  in,  757. 
primary,  756. 
secondary,  756. 
treatment  of,  764. 
lodin  in  treatment  of  tuberculosis,  581. 
Iron  in  anemia,  621. 
Ischiorectal  ab.scess,  tuberculous,  766. 
diagnosis  of,  767. 
pathology  of,  766. 
symptoms  of,  766. 
treatment  of,  768. 
Isotherms  in  the  United  States,  699. 

Japanese     and     Chinese,      tuberculosis 
among,  129-1.30. 
etiology  of,  129. 
Joints,  tuberculosis  of,  735. 
carpus  and  tarsus,  743 
characteristics  of,  738,  739. 
diagnosis  of,  738. 
inoculation  in,  738. 
Von    Pirquet's    phenomenon    in, 

738. 
Wright's  demonstration  of  opsonic 
index  in,  739. 
forms  of,  737. 
hydrops,  737. 
tuberculous  suppurative  arthritis, 

737,  738. 
tumor  albus,  737,  738. 
hip,  744.     See  also  under  Hip-Joint, 
knee,  748. 
prognosis  of,  736. 
shoulder,    742.  See    also    under 

Shoulder-Joint, 
symptoms  of,  735. 
synovial  membrane  in,  736. 
treatment  of,  739. 

Mosetig's     glycerin-iodoform     in, 

740. 
surgical,  739,  741-742. 
arthrectomy  in,  742. 
X-ray  examination  of,  740,  741. 
Journals  devoted  to  prevention  of  tuber- 
culosis, 424. 


916 


INDEX 


Kidney,  tuberculosis  of,  785.      See  also 

Renal  Tuberculosis. 
Kissing,  a  source  of  infection,  32. 
King's  "lean-to,"  647,  648,  649,  651. 
King's  Sanatorium,  657. 
Klebs's    (A.  C),  plans   for   sanatorium, 

656,  657. 
Knee-joint,  tuberculosis  of,  748. 
Knopf's    instructions    to    physicians    in 

private  practice,  813,  818. 
Knopf's  window  tent,  482. 
Koch,  experiments  of,  35. 
Kress's  suggestions  to  mothers,  808-810. 

Lakewood,  N.  J.,  702. 

Languor  in  tuberculosis,  172,  336. 

Laryngeal  medicator  of  Mannheimer  and 
Yankauer,  828. 

Laryngeal  tuberculosis,  formulary  for, 
827. 

Laryngitis,  tuberculous,  638. 

Larynx  in  tuberculosis,  197. 

Latent  tuberculosis  in  childhood,  fre- 
quency of,  112. 

Lecithin  in  treatment  of  tuberculosis, 
582. 

Lectures,  popidar,  554,  561. 

Lectures,  popular,  413. 
public,  416. 

Leprosy,  240. 

Leucocytosis-producing  drugs  in  tuber- 
culosis, 579. 
cinnamic  acid,  580. 
nucleic  acid,  580. 

Limitation  of  motion  of  diajihragm,  276. 

Lobar  pneumonia,  tuberculous,  73. 

Local  tuberculosis,  26. 

Localization,  331,  389,  720,  1021. 

Localization  of  tubercle  bacilli  at  i)oint  of 
entrance,  a  sign  of  resistance, 
88. 

Loomis's  Sanatorium,  648,  649.  650,  652. 

Los  Angeles,  Cal.,  715. 

Low  altitudes,  687. 

Lung  tissue,  use  of,  in  treatment  of 
tuberculosis,  568. 

Lymph  glands,  tuberculosis  of,  723. 
cervical,  728. 

operative  treatment  of,  728. 
extirpation  of  nodes  in,  728. 
precautions  in,  729. 


Lymph  glands,  tuberculosis  of,  cervical, 
operative  treatment  of,  skin  in- 
cision in,  728. 
diagnosis  of,  725. 
differential  diagnosis  of,  725. 
etiology  of,  724. 
histology  of,  723. 
in  childhooil,  144. 

clinical  stages  of,  143. 
progression  of  infection  in,  144. 
breaking  through  of  lymphatic 
system,  145. 
lymi)h  channels  in,  724. 
mixed  infection  in,  724,  725. 
of  axillary  region,  730. 
of  groin,  729. 
skin  in,  724. 
symptoms  of,  725. 
tests  for,  724. 
treatment  of,  726. 
general,  726. 
hygienic,  726. 
medicinal,  726. 
local,  726. 

injections,  726. 
ointments,  726. 
operative,  727. 
curettement,  727. 
extirpation,  727. 
Lymph  nodes,  tuberculosis  of.  74,  389. 
Lymphatic  gland  tissue  used  as  thera- 
peutic agent,  569. 
normal,  569. 
tuberculous,  569. 
Lymjjhatic  tuberculosis,  88. 
Lysins,  97. 

Madeira  as  health  resort,  718. 

Maine  health  resorts,  700. 

Maine  State  Sanatorium,  652,  653. 

Maragliano's  serum,  573. 

Marmorek's  serum,  574. 

Marriage  in  relation  to  tuberculosis.  403. 

Marriage  of  the  tuberculous,  532,  828. 

Marriage  of  the  tuberculous,  409. 

Maryland  Tuberculosis  Sanatorium.  658, 
659,  660. 

Maternity  sanatoria,  444. 

Mattapan,  Boston  Consumptives  Hos- 
pital at,  654,  655. 

Meat  in  tuberculosis,  604. 


INDEX 


917 


Medicinal  climatology,  ideal  of,  670. 
meteorologic  factors  in,  667. 
humidity,  667. 
temperature,  667. 
Medium  altitudes,  687. 
Meninges,  tuberculosis  of,  751.     See  also 

Tuberculosis  of  Meninges. 
Meningitis,  751. 

classification  of,  751. 
diagnosis  of,  751. 
symptoms  of,  751. 
treatment  of,  752. 
Metabolism  in  diagnosis  of  tuberculosis, 

380. 
Metabolism    in    tuberculosis,    292.     See 

also  under  Objective  Signs. 
Mexico,  advantages  of,  for  health  resorts, 

717. 
Microscopic  examination  of  tuberculous 
sputum,  diagnostic  value  of,  20. 
effect  of  acid-fast  bacilli  on,  20. 
Miliary  tuberculosis,  acute,  64. 
a  secondary  disease,  64. 
cause  of,  64. 
nature  of,  65. 
character  of  tubercles  in,  67-68. 
entrance  of  infection  into  blood  in,  65. 
general  tuberculosis  of  thoracic  duct,  a 
cause  of,  66. 
point  of  origin  of,  66. 
localization  of  tubercles  in,  67. 
of  pia  arachnoid,  68. 
organs  involved  in,  67-68. 
pulmonary,  morbid  anatomy  in,  70. 
tuberculous  lesion   of  blood-vessels  a 
source  of,  conditions  necessary, 
65. 
variation  in  number  of  tubercles  in,  67. 
Milk,  in  tuberculosis,  603. 

tuberculous,  474. 
Millet  individual  shack,  647,  650. 
Mixed  and  concomitant  infections,  589- 
599. 
cases  showing  different  tyiJes  of,  596. 
influenza,  590. 
investigation  of,  593. 
by  growing,  594. 
by  opsonic  index,  594. 
by  staining,  594. 
treatment  of,  by  inoculations,  595. 
results  of,  597. 


Mixed  and  concomitant  infections,  varie- 
ties of,  591. 
staphylococcus,  593. 
streptococcus,  592. 
Mixed  infection,  319,  821,  880. 

mixed   infection  in  pulmonary  tuber- 
culosis, 77-78. 
in  tuberculosis  of  lymph  glands,  724, 
725. 
Modes  of  invasion,  52,  111,  810,  933,  953, 

988. 
Modes  of  invasion  of  the  tubercle  bacillus, 
33. 
heredity,     in     33.      See     also    under 

Heredity, 
in  pulmonary  tuberculosis,  34. 
through  digestive  tract,  35,  45. 
through  intestine,  experiments,  38, 
40-44. 
statistics,  38-40. 
through  mouth  and  tongue,  35. 
through  palate  and  gums,  35. 
through    pharynx    and    esophagus, 

36-37. 
through  respiratory  tract,    34,  44- 

45. 
through  stomach,  37-38. 
through  tonsils,  35-36. 
wounds  as,  34. 
Moist  climate,  contrasted  with  dry,  667. 
'Moisture,  effect  of,  on  tubercle  bacillus, 

2.5. 
"Monas  tuberculosum,"  13. 
Morbid    anatomy   of   tuberculosis,    614, 

630. 
Morphin    in   treatment    of   hemorrhage, 

632. 
Mortality  and  social  conditions,  683. 
Mortality  of  tuberculosis,  153. 
Mosetig's  glycerin-iodoform,  740. 
Mothers,  suggestions  to,  808-810. 
Motility  of  chest,  228. 
"Mountain  sickness,"  677. 
Mouth  in  tuberculosis,  96. 
Mulattoes,  tuberculosis  in,  123. 
Municipal  control  of  tuberculosis,  81,  83, 
85,    86,    87.    89,    130,    263.    360, 
615,  629,   744,   908. 
Muscle  plasma  as  a  therai)eutic  agent, 

570. 
Muscles,  tuberculosis  of,  750. 


918 


INDEX 


Naval  and  military  prophylaxis,  497. 

Negro,  tuberculosis  in,  209,  256,  456. 

Negro,  tuberculosis  in,  121-127. 
causes  of,  121-122. 
compared      with      tuberculosis     in 

Indian,  123. 
mortality  in,  123. 
statistics  of,  124-127. 

Nephrectomy,  789. 

Nephrotomy,  789. 

Nervous  system,  effect  of  high  altitudes 
upon,  672,  677,  678. 
in  tuberculosis,  218. 

New  England  health  resorts,  700. 

New  Hampshire  health  resorts,  701. 

New  Jersey  health  resorts,  702. 

New    Mexico,  law    of,    on    tuberculosis, 
423. 
in  contrast  with    Goodsell-Bedell 
Law,  423. 

New  Mexico  health  resorts,  710. 

New  York  City  Health  Department, 
work  of,  in  tuberculosis,  447- 
458. 

New  York  State  health  resorts,  702. 

Night  sweats,  formulary  for,  822. 
treatment  of,  628. 

Nostrums,  3,  541. 

Notification  of  tuberculosis  cases,  com- 
pulsory, 447. 

Nucleic  acid  in  treatment  of  tuberculo- 
sis, 580. 

Nurses,  work  of,  in  tuberculosis,  499. 

Nutrition,  201. 

Nutritives,  826. 

Objective  signs  of  pulmonary  tuberculo- 
sis, 224. 
auscultation  in,  246. 
of  first  stage,  247. 

"dry  crackles"  in,  253. 

feeble  breathing  in,  249. 

granulation  respiration  in,  248. 

harsh  respiration  in,  250. 

interrupted  breathing  in,  249. 

prolonged  expiration  in,  251. 

puerile  breathing  in,  252. 

rales  in,  252. 

undue     transmission     of     heart 
sounds  in,  252. 

vocal  resonance  in,  252. 


Objective  signs  of  pulmonary  tuberculo- 
sis, auscultation  in,  of  second 
stage,  254. 

bronchial  breathing  in,  255. 

bronchovesicular     breathing     in, 
255. 

difficulties  encountered  in,  259. 

emphysema  in,  262. 

enlarged  bronchial  glands  in,  262. 

fine     moist     or     "  subcrepitant " 
rales  in,  256. 

fine  or  medium  friction  sounds  in, 
257. 

muscle  sounds  in,  259. 

of  voice,  260. 

second  pulmonic  sound  accentu- 
ated in,  260. 

sibilant  inspiration  in,  256. 

subclavian  systolic  nmrmur  in,  260. 
of  third  stage,  263. 

amphoric  breathing  in,  265. 

amphoric  voice  in,  264. 

bronchial  or  tubular  breathing  in, 
264. 

cavernous  breathing  in,  264. 

large  moist  rales  in,  265. 

metallic  tinkle  in,  266. 

vocal  resonance  in,  267. 

whi.spering  pectoriloquy  in,  267. 
single-phase,  247. 
blood  changes  in,  285. 

bacteriology  of,  291.  , 

chemistry  of,  292. 

in  coloring  matter,  287. 

in  first  stage,  286. 

in  second  stage,  286. 

in  third  stage,  287. 

leucocytes  in,  288. 

in  chronic  cases,  291. 
inspection  in,  244. 
facies  in,  231. 
of  mouth,  231. 

follicular  pharyngitis  in,  232. 

teeth  in,  231. 

tongue  in,  231. 
rickets,    influence   of,    on   shape   of 

chest,  230. 
scapulae  in,  230. 
scoliosis  in,  230. 
sinking  of  sternum  in,  229. 
skin  of  chest  in,  231. 


INDEX 


919 


Objective  signs  of  pulmonary  tuberculo- 
sis, inspection  of  chest  in,  224. 
distortion  of  thorax  in,  229. 
general,  230. 
local,  230. 
form  of  chest  in,  224. 
barrel-shaped,  226. 
diagnostic  importance  of  changes 

in,  226. 
funnel,  230. 
in  incipient  cases,  224. 
paralytic,  224. 
motility  of  chest  in,  228. 
changes  in,  228. 
in  adv'anced  stage,  228. 
in  early  stage,  228. 
retardation  of,  228. 
mensurati(Hi  in,  233. 
corpulence  in,  236. 
of  chest,  asymmetry  in,  234. 
circumference  of,  233. 
expansion  of,  233. 
lead  tape  cystometer  in,  235. 
spirometer  in,  235. 
weight  in,  236. 
metabolism  in,  292. 
normal,  292. 
of  tuberculosis,  293. 
gaseous,  296. 

loss  from  sputum  and  sweats  in, 
,  294. 

loss  of  indiean  in,  296. 
loss    of    mineral    substances    in, 

295. 
loss  of  nitrogen  in,  293. 
poor  absorptive  power  in,  294. 
undernourishment   in,   from   ano- 
rexia, 294. 
palpation  of  chest  in,  232. 
for  apex  beat,  233. 
in  advanced  cases,  232. 
vocal  fremitus  in,  232. 
percussion  of  chest  in,  237. 
auscultatory,  246. 
of  first  stage,  238. 
dullness  in,  239. 

seat  of,  239. 
effect  of  soft  and  bony  parts  of 

thorax  upon,  239. 
impaired  resonance  in,  238. 
of  apices,  237,  238. 


Objective  signs  of  pulmonarj^  tuberculo- 
sis,  percussion  of  chest  in,   of 
second  stage,  240. 
dislocation    of    apex    outline    in, 

240. 
dullness  on  anterior  of  chest  in, 

241. 
dullness  on  posterior  of  chest  in, 

242. 
enlarged  bronchial  glands  in,  242. 
hyjjerresonance  in,  241. 
tympanitic  overtone  in,  240. 
of  third  stage,  243. 

cracked-pot    resonance    in,    243, 

245. 
tone  changes  in,  244. 
tympany  in,  243. 
tyjjical  .signs  of  cavity  in,  243. 
amphoric  note,  244. 
emphysema,  245. 
tone  changes,  244. 
Roentgen-ray  examination,  268. 

comparative   merits   of   fluoroscopy 

and  radiography  in,  268. 
in  normal  thorax,  271. 
in  pulmonary  tuberculosis,  274. 
of  first  stage,  274. 

limitation    of   motions    of    dia- 
phragm in,  276. 
shading  of  apex  region  in,  276. 
shadows    of    enlarged    bronchial 

glands  in,  278. 
of  second  stage,  281. 
emphysema  in,  281. 
pericardial  effusion  or  dilatation 

of  right  ventricle  in,  283. 
pleural  thickening  in,  282. 
small  pleuritic  effusions  in,  282. 
of  third  stage,  283. 

cardiac  displacements  in,  285. 
signs  of  excavation  in,  283. 
Ocean  climate,  684. 
on  coast,  686. 
on  islands,  685. 
on  sea  voyages,  685. 
physiologic  properties  of,  685. 
Occupation  and  tuberculosis,   425,   470, 

731.  848,  1051. 
Occurrence  of  tuberculosis.  671,  683. 
Old  Tuberculin,  515. 
Olive  oil  in  tuberculosis,  620. 


920 


INDEX 


Open  resorts,  695. 

climatic  treatment  in,  692. 
Ophthalmo-reaction,  177,  207,  210,    211, 
231,    232,    233,    236,    294,    461, 
573,    657,    857,    904,    917.    925, 
951,  1080. 
Ophthalmo-reaction,  .346,  380. 
Opsonic  index,   91,    171,    172,    208,    225, 
435,    475,    478,    479,    625,    796, 
863,  960,  1063. 
Opsonic  index,  350,  799. 

as  a  measure  of  resistance,  96. 
lower  in  "predisposed"  persons,  83. 
suggestions    and    specific    sources    of 

error  in,  802. 
technic  of,  799. 

I.  Blood  serum,  799. 
II.  Cream,  799. 

III.  Emulsion,  800. 

IV.  "Running  through,"  800. 
V.  Staining,  801. 

VI.  Counting,  801. 

Wright's  demonstration  of,  739. 
Opsonins,  31,  36,  403.  430,  862.  1033. 
Opsonins,  96. 
Organotherapy  in  tuberculoses,  568-571. 

by  blood-cells,  570. 

l)y  lung  tissue,  568. 

by  lym{)hatic-glantl  tissue,  569. 

by  muscle  plasma,  570. 
Origin  of  tuberculosis,  179. 
Overheated     dwellings,     danger     from, 
486. 

Pain  in  tuberculosis,  222,  337. 
neuralgic,  222. 

Paralytic  chest,  224. 

Parks  and  playgrounds,  importance  of, 
in  the  prevention  of  tuberculo- 
sis, 478. 

Pasadena,  Cal.,  716. 

Pasteurization  of  milk,  394. 

home,  resistance  of  tubercle  bacillus  to, 
24. 

Patent  medicines  for  tuberculosis,  pro- 
test against,  416. 

Pathologic  changes  in  repeated  doses  of 
tuberculin,  555. 

Pathological  anatomy  of  tuberculosis, 
221,  244,  329,  638,  849,  883, 
937. 


Pathology  of  tuberculosis,   21,   61,   100, 
333,    340,    341,    605,    614,    630, 
645,    662,    746,    787,    802,    1004, 
1013. 
Pennsylvania  health  resorts,  703. 
Peritoneal  tuberculosis,  771. 
classification  of,  771. 
diagnosis  of,  774. 

inoculation  in,  774,  775. 
tuberculin  in,  774. 
occurrence  of,  771. 
symptomatology  of,  772. 
in  adhesive  form,  773. 
in  ascetic  form,  772. 
in  cheesy  form,  773. 
treatment  of,  775. 
Peritoneum,  simple  tuberculo.sis  of,  771, 

772. 
Peritonitis,  tuberculous,  187,  771,  772. 
adhesive,  772. 
a.scitic,  772. 
cheesy,  772. 
"Perlsucht,"  14. 
I'iiarynx,  tuberculosis  of,  58. 
Phthisiophobia,  409. 
Federal,  418. 
State,  420. 
Physical  condition,  relation  of  climate  to, 

663. 
Physical  diagnostic  measures,  385. 
Physical  examination  in  tuberculo.sis,  6, 
191,    226,    251,    297,    358.    369, 
462.    650.    729,    789,    838.    909, 
910.   919,   1012,    1014,   1039. 
Physical  examination  in  tuberculosis,  297. 
examination  itself  in,  .302. 

auscultation  in,  technic  of,  316. 
body  measurements  in,  303. 
chest  examination  in,  304. 
inspection  in,  305. 

laryngeal,  oral,  and  nasal  examina- 
tion in,  303. 
mensuration  in,  306. 
palpation  in,  306. 
percu.s.sion  in,  apical,  312. 

technic  of,  308. 
position  in,  318. 

X-ray  examination  in,  304,  320, 
technic  of.  320. 
examining  room  in,  298. 
equipment  of,  297. 


INDEX 


921 


Physical    examination    in    tuberculosis, 
history  in,  300. 
childhood,  301. 
family,  300. 
of  habits,  301. 

of  past  life  and  sicknesses,  301. 
present  sickness  in,  301. 
time  of,  299. 
Physical  signs  in  diagnosis  of  tubercu- 
losis,  136,    489,   593,    594.   601, 
632,  705,  794,  844,  954. 
Physical  signs  of  pulmonary  tuberculosis, 

value  of,  1  ")8. 
Physicians,  in  public  tuberculosis  insti- 
tutions, remuneration  of,  447. 
instructions    to,    in   private    jiractice, 
813-818. 
Physiologic  reactions  in  high  altitudes, 

672,  676. 
Physiologic  rest,  princii)les  of,  679-680. 
Physiology  of  tuberculosis,  218,  326,  617. 
Pneumonia,  acute  caseous,  154. 
in  tuberculosis,  220. 
tuberculous,  72. 
Pneumonia  and  tuberculosis,  482. 
Pneumothorax,  158. 
Pneumo-tuberculosis,  330. 
Popular  lecture,  413. 
Predisposition   to   tuberculosis,    50,    99, 

242,  468,  609,  661.  847,  946. 
Predisposition  to  tuberculosis,  82,   118- 
119.     See  also  Susceptibility, 
acquired,  87. 

"deminerahzing"  theory  of,  98. 
due  to  deficiency  of  cells,  82. 
due  to  deficiency  of  salts,  83. ' 
hereditary,  98. 

of  efjual  importance  to  acquired  dis- 
position, 98. 
in  childhood,  146. 

diseases  causing,  146. 
influence   of   inherited   structural   de- 
fects on,  84. 
influence  of  sex  on,  83. 
inherited,  83. 

inherited  structural   defects  in,  shape 
of  chest,  84-85. 
size  of  heart  and  lungs,  85. 
structural  anomalies  of  upper  tho- 
racic aperture  a  factor  in,  98. 
various  other  defects,  85. 


Predisposition  to  tuberculosis,  local,  86. 
of  lung  apices,  86. 
lower  opsonic  index  in,  83. 
Prejudice  against  consumptives,  417. 
Prepared  foods  in  tuberculosis,  604. 
Prescott,  Ariz.,  713. 
"Preventatorium,"  446. 
Prisons,    tuberculosis   in,   528,  540,  807, 

911,  944. 
Prisons,  tuberculosis  in,  498. 
Prisons     and     reformatories,      tubercu- 
losis in,  465-472. 
Prognosis  in  tul>erculosis,  131,  132,  156, 
216,    687,    870,    898,    992,    1081. 
Prognosis  in  tuberculosis,  387. 
Prognostic  value  of  reactions  in  tuber- 
culosis, 381. 
Prophylaxis  and  prevention  of  tubercu- 
losis, 1,  2,  25,  68,  81,  82,  83,  85, 
86,    87,    88,    89,    107,    124,    173, 
181.    193,    239,    250,    255,    256, 
261,    262,    265,    267.    268,    269, 
295,    302,    309,    312,    313,    324, 
350,    362,    363,    378,    380,    404, 
405,    433,    448,    458,    460,    467, 
483,    484,    488,    502,    503,    507, 
508,    515,    518,    519,    520,    524, 
526,    527,    530,    533,    534,    535, 
536,    537,    543,    546,    547,    552, 
554,    561,    565,    566,    600,    644, 
682,    686,    699,    709,    714,    722, 
723,    726,    744,    805,    806,    809, 
854,    889,    892,    899,    900,    932, 
974,  978,  984,  1027,  1049,  1059. 
Prophylaxis  of  tuberculosis,  391. 
cla.ss  method  at  home,  441. 
common  house  fly  in,  campaign  against, 

487. 
dry  air  anil  ilanger  from  overheated 

dwellings  in,  486. 
dry  sweeping  in,  danger  from,  486. 
emigration  from  city  to  village  in,  479. 
in  healthy  individual,  393. 
during  adult  life,  400. 
dwellings  in,  403. 
good  physique  in,  400. 
habits  in,  401. 
marriage  in,  403. 
occupation  in,  402. 
during  childhood,  397. 

bathing  and  exercise  in,  398. 


922 


INDEX 


Prophylaxis  of  tuberculosis,  in  healthy 
individual,    during    childhood, 
clothing  in,  398. 
food  in,  397. 
habits  in,  398. 
rules  in,  399. 
schooling  in,  399. 
sleep  in,  398. 
during  infancy,  393-397. 
accidents  in,  395. 
active  immunization  in,  397. 
digestive  disturbances  in,  395. 
diseases  in,  395. 
enlarged  tonsils  in,  395. 
general  hygiene,  climate,  etc.,  in, 

397. 
handkerchiefs,  pets,  etc.,  in,  394. 
immunized  milk  in,  396. 
inoculation  tuberculosis  in,  395. 
isolation  in,  396. 
milk  in,  393. 
special  measvwes  in,  396. 
of  nontuberculous  parentage,  393. 
of  tuberculous  parentage,  396. 
pasteurization  of  milk  in,  394. 
traveling  in.  394. 
tuberculous  relatives  in,  394. 
visiting  public  resorts  in,  395. 
during  period  of  puberty,  400. 

overstrain  in,  400. 
during  youth,  400. 
in  tuberculous  individuals,  404. 

closed   pulmonary   tuberculosis   in, 

405. 
closed  tuberculosis  in,  404. 
duty  of,  to  society,  408. 
duty  of  society  to,  408. 
phthisiophobia,  409. 
marriage  in,  409. 
open  tuberculosis  in.  405. 

care    of    excretions    other    than 

sputum,  408. 
care  of  sputum,  405. 
cough  discipline,  406. 
cuspidors,  406. 
disinfection,  406. 
personal  cleanliness,  408. 
scrofulosis  in,  405. 
individual,  393-409. 
introductory,  391-392. 
public  measures  in,  410. 


Prophylaxis  of  tuberculosis,  public  meas- 
ures in,  administrative  control, 
497. 

advice  and  care  stations,  438^39. 

agricultural  and  horticultural  colo- 
nies, 447. 

antituberculous  work  among  factory 
workers,  492. 

books,  circulars,  etc.,  a  means  of  en- 
lightening the  i)ublic,  431. 

care  of  tuberculous  federal  em- 
ployees, 463. 

care  of  tuberculous  in  almshouses, 
asylums,  and  boarding  schools, 
465. 

care  of  tuberculous  insane,  463. 

children's  school  farms,  498. 

class  method  at  home.  441. 

compulsory  examination  of  children, 
496. 

compulsory  notification  of  tubercu- 
losis cases,  447. 

compulsory  registration,  in  the 
United  States,  of  tuberculous 
cases,  458-463. 

day  and  night  camps,  497. 

day  camps,  440. 

duty  of  munici]>ality  toward  family 
of  consumptive,  446. 

economic  loss  to  commonwealth 
through  tuberculosis,  414. 

economic  meaning  of  tuberculosis, 
495. 

federal  phthisio])hobia.  418. 
results  of,  422. 

ferryboat  day  camp,  441. 

Goodsell-Bedell  Law.  420. 

New  Mexico  Law  in  contrast  to, 
423.  I 

handbills  and  invitations  to  lectures, 
414. 

historical  review  of,  410-414. 

housing  of  the  masses,  477. 

in  prisons,  498. 

in  regard  to  domestic  animals,  473. 

insurance  against  tuberculosis,  493. 

insurance  of  workmen  against  sick- 
ness, 500. 

itinerant  exhibit  of  Kensington,  431. 

journals  devoted  to  prevention  of 
tuberculosis,  424. 


INDEX 


923 


Prophylaxis  of  tuberculosis,  public-  meas- 
ures  in,  local   antituberculosis 

associations,  413. 
maternity  sanatoria,  444. 
medical  mission  of  the  sanatorium, 

445. 
naval  and  military,  497. 
New  Mexico,  Law  of,  423. 
object  of  the  tuberculosis  clinic,  434. 
open-air  tuberculosis  exhibit  of  Dr. 

Oscar  H.  Rogers,  429-430. 
parks  and  playgrounds,  478. 
patent   medicines,    protest   against, 

416. 
plan  of  tuberculosis  clinic,  435—436. 
popular  lecture,  413. 
prejudice  against  consumptives,  417. 
"preventatorium,"  446. 
prevention    of    tubercidosis    in    the 

school  child,  488. 
prostitution,  498. 
public  lecture,  character  of,  416. 
public  press  and  tuberculosis,  424. 
public  schools,  colleges,  etc.,  499. 
raising  funds  for,  495. 
remuneration  of  physicians  in  pul)lic 

tuberculosis  institutions,  447. 
resolutions     of     the     International 

Congress,  1908,  500. 
sanitation  of  workshops,   factories, 

stores,  etc.,  492. 
schools  of  forestry,  creation  of,  479. 
seaside    and    inland    sanatoria    for 

tuberculous  children,  439. 
slaughterhouses,  supervision  of,  474. 
social    mission   of    the   sanatorium, 

445. 
special  disjiensaries,  496. 
special  work  of  Tuberculosis  Com- 
mittee  of   the   C.    O.    S.,   New 

York,  442. 
State  phthisiophobia,  420. 

results  of,  422. 
"sure  consumption  cures,"  protest 

against,  416. 
tenement-hou.se  laws,  477. 
trained  nurses,  work  of,  499. 
tuberculosis  clinic,  43.3-438. 
tuberculosis  exhibition  held  in  New 

York  City,  1908,  426-429. 
tuberculosis  exhibits,  425-433. 


'   Prophylaxis  of  tuberculosis,  public  meas- 
ures   in,    tuVjerculosis    in    pris- 
ons   and    reformatories,    465- 
472. 
tuberculous  milk,  protection  against, 

474. 
work  of  health  department,  447-458. 
sanitation  at  home  in,  481. 
window  tent  for  oi^en-air  treatment  at 
home  in,  482. 
Prostitution  and  tuberculosis,  498. 
Pseudo-tubercle  bacillus,  19. 
cultures  of,  20. 
differentiation  of,  from  true  tubercle 

bacillus,  18,  20. 
inoculation  of  animals  with,  20. 
isolation  of,  by  Moeller,  19. 
occurrence  of,  19. 

relation  of,  to  true  tubercle  bacillus, 
20. 
Psychical  condition,  relation  of  climate 

to,  663. 
Psychosis,  196. 

Public  instruction  in  preventive  measures 
of    tuberculosis    by    means    of 
books,  circulars,  etc.,  431. 
Public  lecture,  character  of,  416. 
Public  measures  in  prophylaxis  of  tuber- 
culosis, 410. 
historical  review  of,  410. 
Public  press  and  tuberculosis,  424. 
Public  schools,  colleges,  etc.,  prophylaxis 

against  tuberculosis  in,  499. 
Pulmonary  gymnastics,  613. 
Pulmonary  tuborcuNjsis,  6,  22,  23,  63,  90, 
94.  97,  102,  104,  106,  150,  161, 
179,    217,    308,    320,    321,    328, 
330,    364,    365,    366,    408,    618, 
774,    829,    834,    894,    901,    931, 
937,    940,    941,    980,    987,    992, 
1015,    1039,    1055. 
Pulmonary    tuberculosis,    acute,    symp- 
toms of,  153. 
disseminated,  153. 
acute  caseous,  symjjtoms  of,  153. 
acute  general  hematogenous,  70. 

morbid  anatomy  of  lungs  in,  70. 
acute  miliary,  155. 

broncho-pulmonary,  157-158. 

modification  of,  158. 
pleural,  158. 


924 


INDEX 


Pulmonary  tuberculosis,  acute  miliary, 
tyi^hoid  type  of,  155-157. 
acute  ulcerative  lobular,  symptoms  of, 

153. 
bronchopneumonia  in,  72. 
chronic,  definite  symptoms  of,  150. 
fibrosis  in,  152. 
latent,  symptoms  of,  151. 
symptoms  of,  150. 
differentiation     between     acute     and 

chronic  tyj)es  of,  153. 
hectic  fever  in,  162. 
infection  of,  in  early  life,  112. 
latent,  88. 
locaHzed,  71. 

lobar  pneumonia  in,  73. 
process  of  evolution  of,  71-72. 
mixed  infection  in,  77. 
modes  of  invasion  in,  34. 
morbid  anatomy  of,  69-77. 

acute  general  hematogenous,  70. 

localized,  71. 

partial  disseminated  hematogenous, 

70. 
ulcerative,  74. 

variety  of  anatomic  alterations  in, 
69. 
nonmiliary,  hematogenous,  62. 

lymphogenous,  62. 
partial  disseminated  hematogenous,  70. 
physical  signs  in,  158. 
pneumonia  in,  72. 
predisposition  of  apical  parts  of  lungs 

to  infection  in,  62. 
previous,  a  danger  for  reinfection,  88. 
primary,  air-borne  infection  of  lungs 
cause  of,  62. 
predisposing    factor    to    secondary 
autoinfection,  88. 
quiescent  or  healed,  78-79. 
relative    frequency    of    primary    and 

secondary  localization  in,  62. 
subjective  symptoms  of,  159.    See  also 

Subjective  Symptoms, 
symptoms  of,  149.     See  under  Symp- 
toms, 
differentiations  of  types  in,  149. 
value  of,  158. 
ulcerative,  74. 

bronchiectasis  in,  75. 
bronchopneumonia  in,  75. 


Pulmonary  tuberculosis,  ulcerative,  cavi- 
ties in,  75. 
hemorrhage  in,  76. 
morbid  anatomy  of,  74. 

Radiography,  268. 

Rainfall,  mean,  for  dilTerent  parts  of  the 

United  States,  699. 
Rales,    fine    moist,    or    "subcrepitant," 
256. 
large  moist,  265. 
Reclining  chairs,  841-843. 
Recognition    of   stages   of    tuberculosis, 

361-363. 
Recording  findings  in  examination,  374- 
376. 
chest  diagrams  in,  365-374. 
signs  for,  377-378. 
Recovery   from   tuberculosis,    194,    258, 

692. 
Registration  and  report  of  tuberculosis 
cases,   act  providing  for,   811- 
812. 
Registration   of  tuberculosis  cases,   45, 

274,  801. 
Registration  of  tuberculous  cases,  com- 
pulsory, in  the  United  States, 
4.58-463. 
Relapse,  692. 

Remedy  for  tuberculosis,  565,  566. 
Renal  tuberculosis,  190,  785. 
diagnosis  of,  788. 
l)athology  of,  786. 
symptoms  of,  787. 
general,  786,  787. 
mixed  infection  in,  787. 
l)ain  in,  787. 
tubercle  bacilli  in,  787. 
urine  in,  787. 
treatment  of,  788. 
medical,  788. 
nephrectomy,  789. 
nephrotomy,  789. 

operative,     points     considered     in, 
790. 
Resistance    of    tuberculosis,    7,    8,    32, 

869. 
Resistance  to  tuberculous  infection,  80- 
93. 
in  animals  in  general,  80. 
in  men,  80. 


INDEX 


925 


Resistance  to  tuberculous  infection,  in- 
creased, 91. 
by  occupation,  91. 
by  physiologic  measures,  91. 
in  diathesis,  92. 
in  diseases,  92. 
in  asthma,  92. 
in  emphysema,  92. 
in  mitral  heart  disease,  92. 
specific,  92. 

in  chronic  lupus,  92. 
in  "inherited"  cases,  92. 
individual,  80. 
lessened  by  overw^ork,  101. 

by  worry,  101. 
localization  of  tubercle  bacilli  at  i>oint 

of  entrance,  a  sign  of,  88. 
normal  physiologic,  81. 
influence  of  age  on,  81. 
influence  of  heredity  on,  81. 
nature  of,  82. 
subnormal,  82. 
acquired,  87. 

due  to  deficiency  of  cells,  82. 
due  to  deficiency  of  salts,  83. 
due  to  previous  tuberculous  infec- 
tion. 87. 
lymphatic,  87. 
pulmonary,  88. 
influence  of  inherited  structural  de- 
fects on,  84. 
shape  of  chest,  84-85. 
size  of  heart  and  lungs,  85. 
various  other  defects,  85. 
influence  of  sex  on,  83. 
inlierited,  83. 
local,  86. 

of  lung  apices,  86. 
lower  opsonic  index  in,  83. 
Resorts.     See  Health  Resorts. 

comparison  between  open  and  closed, 
695. 
Respiration,  diseases  of  organs  of,  1048. 
Rest,    physiologic,    principles    of,   679- 

680. 
Rest  in  tuberculosis,  613. 
Ribs,  tuberculosis  of,  734. 
Rickets  and  shape  of  chest,  230. 
Rocky   Mountains,    advantages   of,    for 

health  resorts,  707. 
Rooms  of  tuberculous  patients,  610. 


San  Diego,  Cal.,  716. 

Sanatoria,  24,  43,  44,  49,  75,   105,   112, 
117.    147,    151,    154,    170,    187, 
190,    202,    261,    264,    305,    327, 
443,    470,    481,    490,    510,    513, 
516,    523,    529,    543,    557,    558, 
576,    583,    621,    676,    769,    770, 
800,    872,    971,    973,    977,    979, 
1010,  1018,  1051. 
Sanatoria,  climatic  treatment  in,  692. 
for  tuberculous  children,  439. 
seaside  and  inland,  439. 
Sanatorium,  640. 

administration  building  in,  657. 

Agnes  Memorial,  652,  653. 

l)uilding  material  and  cost  of,  658. 

definition  of,  640. 

essentials  in  design  of,  656. 

Gaylord  Farm,  648,  651. 

history  of,  640-<i41. 

King's,  657. 

Klebs's  (A.  C.)  plans  for,  656,  657. 

Loomis,  648,  649,  650,  652. 

Maine  State,  652,  653. 

management  and  regime  of,  661. 

Maryland     Tuberculosis,     658,     659, 

660. 
medical  mission  of,  445. 
patients'  quarters  in,  646. 

ideal  sleeping  unit  in,  647. 
planning  and  construction  of,  645. 
administrative  part,  646. 
sleeping  accommodations,  646. 
requirements  for  selection  of  site  of, 
643. 
absence  of  smoke  and  noise,  644. 
accessibility,  644-645. 
cheerful  landscape,  644. 
dry  soil,  644. 
large  grounds,  645. 
requisites  of,  641-643. 
social  mission  of,  445. 
Sanatorium   building,   general   i)lanning 

of,  658. 
Sanitary  devices,  832-840. 
Sanitation  at  home,  481. 
Sanitation  of  workshops,  factories,  stores, 

etc.,  492. 
Santa  Barbara,  Cal.,  717. 
Santa  Fe,  N.  Mex.,  710. 
Saranac  Lake,  701. 


926 


INDEX 


Schema    of    tuberculins    and     tubercle 

bacillus  vaccines,  511. 
School  children,  prevention  of  tubercu- 
losis in,  488. 
Schools  of  forestry,  creation  of,  479. 
Scrofulosis,  87,  405. 

a  predisposing  factor  in  tuberculosis, 

87-88. 
in  childhood,  147. 
prognosis  of,  147. 
types  of,  147. 
"Scrofulous  diathesis,"  87. 
Sea  air  in  tuberculosis,  123,  124. 
Sea  Breeze,  702. 
Semeiology,  47. 
Semeiology,  3. 

Seminal  vesicles  and  prostate,  tubercu- 
losis of,  784. 
symptoms  of,  785. 
treatment  of,  785. 
Sensible  temperature,  667-668. 
Serotherapy  in  tuberculosis,  571-575. 
Serum,  agglutination,  reaction,  349. 
heated,  reaction,  352. 
in  tuberculosis,  administration  of,  572. 
antistreptococcic,  575. 
Maragliano's,  573. 
Marmorek's,  574. 
"serum  disease"  from,  573. 
varieties  of,  572. 
"Seruin  disease,"  573. 
Serums,  9,  26,  27,  29,  40,  41,  185,  216, 
317,    347,    433,    451,    465,    607, 
655,    656,    701,    773,    785,    815, 
818,    837,    842,    856,    881. 
Sexual  factor  in  tuberculosis,  763. 
Shoulder-joint,  tuberculosis  of,  742. 
differential  diagnosis  of,  743. 
occurrence  of,  742. 
prognosis  of,  743. 
symptoms  of,  742. 
treatment  of,  743. 
Silver  City,  N.  Mex.,  711. 
Silver  in  treatment  of  tuberculosis,  582. 
Simulation  of  tuberculosis,  22, 
Slaughterhouses,  supervision  of,  474. 
Smegma  bacillus,  occurrence  of,  19. 
Social  aspects  of  tuberculosis,  122,  530, 

534,  551. 
Social  conditions  and  mortality,  G83. 
Social  environment,  690. 


Social  mission  of  sanatorium,  445. 
Sound    measurements    in    tuberculosis, 

168. 
South  Africa,  tuberculosis  in,  647. 
Southern  Pines,  N.  C,  704. 
Specific  therapeutics  of  mixed  and  con- 
comitant infections,  589-599. 
Specific  treatment  of  tuberculosis,  anta- 
gonistic bacteria  in,  565-568. 
"acid-fast"  bacteria,  566. 
attenuated  tubercle  bacilli,  .566. 
bacterium  termo,  565. 
erysipelas,  565. 

products  of  tubercle  bacillus,  567. 
syiihilis,  565. 
vaccination,  567. 
yeast,  566. 
"false  specifics"  in,  575-585. 
alcohol,  578. 

arsenic  and  its  derivatives,  577. 
calcium,  582. 

creosote  and  its  derivatives,  576. 
ichthyol,  581. 
inhalations,  583. 
injections,  584. 
iodin,  .581. 
lecithin,  .582. 

leucocytosi.s-producing  drugs,  579. 
cinnamic  acid,  580. 
nucleic  acid,  580. 
silver,  582. 
sprays,  584. 
strychnin,  583. 
hemotherapy  in,  571. 
historical  introduction  of,  508. 
organotherapy  in,  568-571. 
blood  cells  in,  570. 
lung  tissue  in,  .568. 
lym])hatic  gland  tissue  in,  569. 
normal,  569. 
tuberculous,  569. 
muscle  plasma  in,  570. 
schema    for  tuberculins  and  tubercle 

bacillus  vaccines  in,  511. 
serum  in,  571—575. 

administration  of,  572. 
antistreptococcic,  575. 
Maragliano's,  573. 
Marmorek's,  574. 
"serum  disease"  in,  573. 
varieties  of,  572. 


INDEX 


927 


Specific  treatment  of  tuberculosis,  tuber- 
culin in,  508. 
advice  to  patient  inquiring  about, 

545. 
antipyretic  action  of,  oJH. 
chemistry  of,  517. 
complications  of,  535. 

age  in,  5.35. 

estimation  of  patients'  condition 
in,  535. 
dermic  injections  of,  519. 

inhalation,  510. 

intravenous,  518. 

oral,  518. 

subcutaneous,  519. 
dilutions  of,  520. 

diluents  used  in,  521. 

estimating  of,  521. 

method  of  making,  520. 

preservation  of,  520. 
dose  of,  524. 

beginning,  524. 

final,  535. 

hypersusceptibility  to,  538. 

in  general,  524. 

increase  of,  525. 

clinical  method,  526. 
laboratory  method,  526. 
duration  of  treatment  of,  548. 

repeated  courses  in,  549. 

tuberculin  test  in,  549. 
general  symptoms  of,  532. 
increased  susceptibility  in,  534. 
interval  between  doses  of,  525. 
local  symptoms  of,  531. 
methods  of  admmistration  of,  578. 
organ  reactions  to,  531. 
preparation  for  injections  of,  523. 

accidental  inoculation  in,  523. 

cleansing  of  needles  in,  523. 

cleansing  of  skin  in,  523. 

site  of  inoculation  in,  523. 
prophylactic  use  of,  545. 
pulse  in,  534. 

record  of  treatment  with,  527. 
repeated  doses  of,  551. 

blood  in,  551. 

blood-pressure,  552. 
erythrocytes,  551. 
leucocytes,  551, 
serum,  552. 


Specific  treatment  of  tuberculosis,  tuber- 
culin   in,    repeated    doses    of, 
blood  in,  untoward  result.s,  552. 
complications  in,  555. 

elevated  temperature  in,  554. 
experimental  results  in,  556. 
hemoptysis  in,  555. 
mobilization  of  tubercle  bacilli 
in,  553. 
pathologic  changes  in,  555. 
physical  signs  in,  555. 
sputum  in,  553. 
urine  in,  554. 
weight  in,  551. 
results  of,  556-565. 

loss  of  tubercle  bacilli,  564. 
reports  of,  560-564. 
selection  of,  545. 
selection  of  patients  for,  541. 
age  in,  545. 
complications  in,  544. 
duration  of  disease  in,  545. 
elevated  temperatures  in,  543. 
physical  signs  in,  544. 
symptoms  and  general  condition 

in,  543. 
theory  of  action  in,  541. 
skin  reaction  of,  530. 
small  do.ses  in,  schemata  of,  539. 

value  of,  538. 
temperature  in,  5.32. 
time  of  injection  of,  .')27. 
treatment  during  administration  of, 
550. 
medicinal,  550. 
rest  and  exercise  in,  550. 
rise  of  temperature  in,  550. 
sanatorium,  550. 
vaccines  in,  5.)0. 
typical  reaction  of,  529. 
weight  in,  5.34. 
varieties  of  tuberculin  used  clinically, 
515. 
antii)hthisin,  510. 
Bacillen  Emulsion  (B.  E.),  516. 
Beraneck's  Tuberculin,  516. 
Broth  Filtrate  (B.  F.),  516. 
Old  Tuberculin,  515. 
Tuberculin  R.,  516. 
Tuberculocidin  (T.  C),  516. 
"Watery  lOxtract,"  516. 


928 


INDEX 


Specific  treatment  of  tuberculosis,  work 
presented  at  the  International 
Congress  at  Washington,  585- 
588. 
Spinal  cord,  tuberculosis  of,  755. 
Sprays  in  treatment  of  tuberculosis,  584. 
Sputum,  128,  131,  132,  163,  222,  348,  747. 
Sputum,  care  of,  in  tuberculosis,  4f)5. 
in  repeated  doses  of  tuberculin,  55.'i. 
microscopic  examination  of,  20. 

effect  of  acid-fast  bacilli  on,  20. 
tubercle   bacilli   in  Herman's  method 

of  staining,  17. 
tuberculous,     infection     of     intestine 

through  swallowing  of,  38. 
staining  of  bacilli  in,  15. 
Sputum  examination,  ;>27,  385. 
Stain,  Ehrlich's  anilin  water,  16. 
loss  of,  in  young  tubercle  bacilli,  17. 
Ziehl-Neelson  carbon  fuchsin,  15. 
formula  for,  15. 
method  of,  15. 
Staining,  diagnostic  value  of,  18-10. 
differentiation   between   tubercle   and 
lepra  bacillus  by,  18-19. 
between  tubercle  and  smegma  bacil- 
lus by,  19. 
Oabbett's  method  of,  16. 
in  tissues,  method  of,  18. 
of  bov'ine  bacillus,  15. 
of  human  bacillus,  15. 
of  tubercle  bacillus,  15. 
pseudo-tubercle  bacillus  differentiated 
from   real  tubercle  bacillus  by, 
18. 
relation  of  fat  and  waxy  substances  to, 
18. 
Staining  of  tubercle  bacillus,  19,  174,  641, 

694,  959. 
Staphylococcus  in  tuberculosis,  593. 
State  phthisiophobia,  420. 

results  of,  422. 
Statistics  on  tuberculosis,  354,  841,  1021, 
Sternum,  tuberculosis  of,   734. 
Streptococcus  in  tuberculosis.  593. 
Strychnin  in  anemia,  621. 

in  treatment  of  tuberculosis,  583. 
Subjective     symptoms     of     jiulmonary 
tuberculosis,  159. 
anorexia  in,  175. 
bones  in,  191. 


Subjective  .symptoms  of  pulmonary  tu- 
berculosis, chills  in,  169. 
circulatory  system  in,  178. 
blood-pressure  in,  179. 
high,  179,  180. 
low,  180. 

causes  of,  180. 
heart  in,  ISO. 

dilatation  of,  182. 
displacement  of,  181. 
hypertrophy  of,  182. 
in  animals,  181. 
in  autopsies,  180. 
in  clinical  findings,  180. 
l)ericardial  frictions  of,  182. 
valvular  disea.se  of,  181. 
hypotension  in,  179,  180. 
in  early  cases,  179. 
in  jjrogressive  cases,  179. 
pul.se  in,  178. 
tachycardia,  178. 
causes  of,  178. 
cough  in,  200. 
advanced,  203. 
cold  air  on,  effect  of,  204. 
duration  of,  202. 
incipient,  201. 
laryngeal,  202. 
nature  of,  202. 
on  lying  down,  203. 
personality  on,  effect  of,  202. 
regions  affected  in,  201. 
cyanosis  in,  178. 
digestive  system  in,  182. 
intestinal  canal  in,  18.5. 
constipation  in,  185.        • 
diarrhea  in,  186. 
first  stage  in,  185. 
hemorrhages  in,  187. 
lesions  in,  185. 
peritonitis  in,  187. 
third  stage  in,  186. 
mouth  in,  183. 
pharynx  in,  183. 

follicular  pharyngitis,  183. 
tuberculous  pharyngitis,  183. 
stomach  in,  184. 
anorexia  in,  185. 

dilatation  and  dislocation  of,  184. 
discomfort  in,  184. 
fermentation  of,  184. 


INDEX 


929 


Subjective  sjTnptoms  of  pulmonary  tu- 
berculosis, digestive  system  in, 
stomach  in,  vomiting  in,  184. 
teeth  in,  183. 
tongue  in,  183. 
tonsils  in,  183. 
dyspnea  in,  176. 

in  acute  miliary  type,  176. 
in  advanced  cases,  177. 
in  chronic  type,  176. 
causes  of,  176-177. 
sudden  development  of,  177. 
emaciation  in,  173. 
expectoration  in,  204. 
absence  of,  204. 
inspection  of,  207. 
of  fibroid  cases,  206. 
of  purulent  cases,  206. 
of  ulcerative  cases,  206. 
sputum  of,  amount  of,  206. 

nature  of,  20.5. 
time  of  day  when  commonest,  207. 
fever  in,  159. 

bad  effect  of,  on  digestion,  169. 

evening,  163. 

hectic,  162. 

in  physical  and  mental  disturbances, 

164. 
morning,  163. 

persistently   high   temperature   un- 
favorable in,  168-169. 
remittent,  169. 

temperature,  evening  hyperthermia 
in,  163. 
hectic,  162. 
in  third  stage,  167. 
postprandial,  164. 
temperature  curve,  typical,  162. 
variations  in,  164. 

caused  by  improvement,  16.5. 
caused  by  menstruation,  16.5. 
caused  by   nervous   influences, 

165. 
caused  by  physical  and  mental 

disturbances,  164. 
due  to  congestion,  165. 
due  to  digestive  disturbances, 

166. 
due  to  extending  of  disease,  165. 
due  to    mixed   infection,  167- 
168. 
CO 


Subjective  symptoms  of  pulmonary  tu- 
berculosis, fever  in,  tempera- 
ture curve,  variations  in,  due 
to    other    than    pulmonary 
causes,  166-167. 
in  incipient  cases,  165. 
in  old  cases,  168. 
temperature  observations  in,  160. 
accuracy  of  thermometer  in,  160. 
individual  idiosyncrasy  in,  160. 
rectal  method  of,  161. 
subnormal,  morning,  163. 
taking  of  readings,  161. 
typical  curve  in,  162. 
gain  of  weight  in,  173. 
generative  system  in,  191. 
menstrual  irregularities,  191. 
sexual  desire,  191. 
hair  in,  193. 
hemorrhage  in,  212. 
clinical  picture  of,  216. 
color  of  blood  in,  216. 
quantity  of  blood  in,  216. 
sensations  accompanying,  216. 
conditions    producing,    other    than 
tuberculous.  212. 
tuberculous,  213. 
diagnosis  of,  220-222. 
efTect  of  age  on,  215. 
of  appetite  on,  214. 
of  fatigue  on,  215. 
of  heredity  on,  215. 
of  meteorologic  conditions  in,  214. 
of  pi-emen.strual  period  on,  214. 
of  season  on,  215. 
of  sex  on,  215. 
of  stage  on,  215. 
of  time  of  day  on,  215. 
frequency  of,  214. 
nature  of,  213. 
nervous  system  in,  218. 
physical  signs  of,  217. 
pneumonia  following,  220. 
recurrences  of,  217. 

condition  between.  218. 
results  of,  219. 
hoarseness  in,  171. 
languor  in,  172. 

in  early  stages,  172. 
in  late  stages,  173. 
liver  in,  188. 


930 


INDEX 


Subjective  symptoms  of  pulmonary  tu- 
berculosis, loss  of  weight  in,  173. 
microscopic  examination  in,  207. 
elastic  fibers  in,  207,  208. 
epithelial  cells  in,  207. 
mixed  infection  in,  211. 
sputum  in,  appearance  of,  211. 
tubercle  bacilli  in,  207,  209. 
absence  of,  209,  210. 
number  of,  209. 
position  of,  210. 

sjiutum    containing,    appearance 
of,  211. 
chemistry  of,  211. 
mixed  infection  in,  211. 
tinctorial  qualities  of,  210. 
muscles  in,  191. 
of  larynx,  197. 
anemia,  198. 
aphonia,  200. 
dysphagia,  197,  200. 
hyperemia,  198. 
laryngeal  catarrh,  187. 
larjmgitis,  197. 
perichondritis,  200. 
posterior    commissure    changes    in, 

198. 
vocal  cords  in,  199. 
weak  voice,  197. 
of  special  senses,  190. 
pain  in,  222. 

distinction    between    pleuritic   and 

intercostal,  223. 
neuralgic,  222. 
psychical  condition  in,  193. 
hopefulness,  195. 
hyperalgesia,  196. 
insanity,  196. 
intellect  in,  195. 
neuralgia,  196. 
neurasthenia,  195. 
neuritis,  196. 
normal,  193. 
sleeplessness,  195. 
skin  in,  192. 

clubbed  fingers  in,  193. 
edema  in,  193. 
hectic  flush  of,  192. 
trophic  changes  in,  192. 
sweats  in,  171. 
cause  of,  172. 


Subjective  symptoms  of  pulmonary  tu- 
berculosis,  sweats  in,  in   first 
stage,  171. 
in  second  stage,  171. 
in  third  stage,  172. 
urinary  system  in,  188. 
bladder  in,  188. 
kidneys  in,  188. 
urine  in,  188. 

albuminuria,  189. 
examination  of,  190. 
phosphaturia,  188-189. 
Sudan  III  method  of  staining,  19. 
Sunlight,  destruction  of  tubercle  bacillus 

by,  24. 
Suprarenal  extract  in  hemorrhage,  633. 
Suprarenal  gland,  tuberculosis  of,  791. 
"Sure     consumption     cures,"     protest 

against.  416. 
Surgical  forms  of  tuberculosis,  suscepti- 
bihty  of  cattle  to,  47. 
experiments  in,  47-48. 
Surgical  tuberculosis,  5,  9,  58,  98,  107, 
123,    241,    245,    273,    281,    337, 
338,    356,    357,    359,    379,    464, 
577,    602,    606,    616,    628,    659, 
664,    665,    669,    680,    708,    713, 
717,    728,    750,    754,    762,    792, 
861,    864,    874,    887,    888,    891, 
913,    939,    952,    957,    962,    969, 
998,     1022,    1023,    1024,     1025, 
1026,  1029,  1042,  1050,  1079. 
Surgical  tuberculosis,  723. 
Susceptibility,  39,  209. 
Susceptibility  to  tuberculous  infection 
in  children,  87. 
nonspecific,  89. 

diseases  of  nutrition  in,  90. 
chlorosis,  90. 
diabetes  mellitus,  90. 
gastric  and  intestinal  dyspepsias, 

90. 
rachitis,  90. 
infectious  diseases  in,  89. 

acute  gastro-intestinul  catarrh,  90. 

bronchitis,  89. 

gonorrhea,  90. 

influenza,  89. 

malaria,  90. 

pleuritis,  89. 

pneumonia,  89. 


INDEX 


931 


Susceptibility  to  tuberculous  infection  in 
children,  nonspecific,  infectious 
diseases    in,    rheumatic    fever, 
90. 
syi>hilis,  90. 
typhoid  fever,  89. 
injuries  in,  91. 

surgical  operations  for,  91. 
miscellaneous  diseases  in,  91. 
nervous  diseases  in,  90. 
epilepsy,  90. 
insanity,  91. 
specific,  from  previous  tuberculous  in- 
fection, 87. 
lymphatic,  87. 
pulmonary,  SS. 
Sweats  in  tuberculosis,  171,  337. 
Sweeping,  dry,  danger  from,  48G. 
Symptoms   of   pulmonary    tuberculosis, 
149,  379. 
acute  miliary  type,  1.5.5. 
acute  type,  153. 
caseous,  153. 

beginning  of.  154. 
course  of,  154. 
end  of,  154. 
clinical  picture  of,  153. 
course  of,  153. 
disseminated,  153. 
beginning  of,  154. 
course  of,  rapid,  154. 
end  of,  154. 
prognosis  of,  153. 
acute  miliary,  forms  of,  155. 

bronchopulmonary,  157-158. 

modification  of,  15,S. 
pleural,  158. 
ty})hoid,  155-157. 
diagnosis  of,  1.30. 
resemblance     of,     to     typhoid 
fever,  1.5G. 
chronic  type,  1.50. 
abortive,  151. 
course  of,  151. 
definite,  150. 
cough  in,  1.50. 
expectoration  in,  1.50,  151 
fever  in,  151. 
hemoptysis  in,  151. 
duration  of,  1.52. 
fibrosis  in,  152. 


Symptoms   of    pulmonary   tuberculosis, 
chronic  type,  final,  151. 
improvement  in,  153. 
initial,  loss  of  vitality  in,  150. 

other  diseases  in,  150. 
latent,  151. 

mistaken  for  dyspepsia,  150. 
for  heart  trouble,  1.50. 
for  neurasthenia,  1.50. 
prognosis  of,  152. 
ulceration  in,  152. 
differentiation  of  types  in,  149. 
introductory,  149. 
objective,  224.      See  under  Objective 

Signs, 
subjective,  159.     See  under  Subjective 

Symptoms, 
value  of,  158. 
Symptoms  of  tuberculosis,  12,  136,  439, 
450,    633,    703,    711,    936,    963, 
990,    991,    1004. 
Synovial  membrane,  736. 
arthrectomy  in,  742. 

Tachycardia,  178. 
Teachers,  suggestions  to,  804-807. 
Temperature,  mouth,  96. 
Temperature,  rectal,  121. 
Temperature,  667. 

elevated,  in  repeated  doses  of  tuber- 
culin, 554. 
sensible,  667-668. 

as  compared  with  physical,  667. 
theories  explaining,  667-668. 
Tenement  house  laws,  477. 
Tent  life,  609. 

Tents  and  tent  houses,  844-852. 
Testicles,  tuberculosis  of,  778. 
causes  of,  779. 
diagnosis  of,  780. 
occurrence  of,  779. 
pathology  of,  779. 
symptoms  of,  779. 
in  acute  form,  780. 
in  chronic  form,  780. 
treatment  of,  781. 
expectant,  781. 
operative,  782. 
castration,  783. 
ei)ididymectomy,  782. 
palliative,  782. 


932 


INDEX 


Testicles,  tuberculosis  of,  treatment  of, 
operative,  radical,  782. 

Thomasville,  Ga.,  706. 

Thorax,  shape  of,  78,  80,  152. 

Thorax,  shape  of,  in  tuberculosis,  441, 
453. 

Tonics,  appetizing  and  bitter,  G07. 

Toxic  formation,  absence  of,  in  tubercle 
bacillus,  29. 

Toxins  and  antitoxins,  339. 

Transfusion,  409. 

Transmission  of  infection,  230,  322,  323, 
721,  795,  912. 

Transmission  of  tuberculosis,  13,  25, 
389,  721. 

Treatment  of  tuberculosis,  general,  21, 
24,  43,  69,  93,  103,  123,  124, 
125,  129,  139,  277,  279,  290, 
291,  314,  333,  345,  351,  390, 
393,  457,  484,  494,  496,  497, 
498,  500,  507,  509,  510,  513, 
525,  542,  544,  545,  555,  556, 
557,  559,  565,  566,  584,  592, 
599,  603,  610,  612,  634,  649, 
663,  666,  670,  679,  680,  682, 
685,  688,  691,  719,  720,  742, 
793,  799,  825,  846,  893,  1008, 
1009,  1031,  1032,  1041,  1054, 
1065. 

Treatment  of  tuberculosis,  specific,  8,  28, 
46,  73,  134,  140,  169,  203,  206, 
208,  235,  237,  246,  275,  317, 
332,  335,  343,  347,  355,  374, 
485,  618,  621,  653,  654,  675, 
700,  701,  702,  719,  750,  756, 
766,  792,  811,  815,  818,  858, 
862,  868,  877,  878,  884,  886, 
893,  896,  914,  920,  942,  943, 
950,  955,  964,  965,  966,  979, 
977,  980,  981,  983,  998,  1005, 
1006,  1030,  1034,  1037,  1038, 
1056,    1066,    1074,    1075,    1082. 

Treatment  of  tul)erculosis,  surgical,  712, 
847,  1050. 

Treatment   of   tuberculosis,   antagnostic 
bacteria  in,  .56.5-568. 
climatic,  66.3. 

"false  specifics"  in,  575-.585. 
general,  600. 

air  and  environment  in,  608-612. 
in  city  life,  608. 


Treatment  of  tuberculosis,  general,  air 
and  environment  in,  in  home 
life,  610. 
cuspidors,  610. 
daily  routine,  611. 
floors,  610. 
rooms,  610. 
in  tent  life,  609. 
clothing  in,  616. 

exerci.se  in,  graded  system  of,  613. 
tests  for  discharge  by,  615. 
pulmonary  gymnastics  in,  613. 
untoward  results  of,  616. 
walking  in,  613. 
food  in,  601. 
alcohol,  604. 

appetizing  and  bitter  tonics,  607. 
carbohydrates,  605. 
dietaries,  605-607. 
eggs,  603. 
fat,  605. 
meat,  604. 
milk,  603. 

prepared  foods,  604. 
weight  gained  by,  602. 
food  values  in,  602. 
hardening  in,  617. 
hydrotherapy  in,  617. 
rest  in,  613. 
home,  by  sanatorium  methods,  600. 
introduction  to,  505-507. 
of  complications,   635-639.     See  also 
imder  Complications, 
diarrhea,  6.39. 
empyema,  637. 
insomnia,  635. 
ischiorectal  abscess,  637. 
])ain,  636. 

pityriasis  versicolor,  637. 
pleurisy  with  effusion,  636. 
pneumothorax,  637. 
tuberculous  laryngitis.  638. 
sanatorium,  640. 

specific,  508.     See  also  under  Specific 
Treatment, 
antagonistic  bacteria  in,  565-568. 
symptomatic,  618. 
anemia  in,  620.   * 
arsenic  in,  621. 

cardiac  weakness  and  dyspnea  in, 
634-635. 


INDEX 


933 


Treatment  of  tuberculosis,  symptomatic, 
cough  in,  (i24. 
catarrhal  inflammations  and  their 
treatment  in,  625. 
by  applications,  62o. 
by  inhalers,  626. 
causes  of,  624,  625. 
remedies  for,    administration    of, 
627. 
for  excessive  secretion,  627-628. 
for  insistent  and  rasping  cough, 

627. 
for  tight  cough,  627. 
debility  in,  618. 
fever  in,  622. 

hydrotherapy  in,  623. 
medicines  in,  622. 
rest  and  food  in,  622. 
gastro-intestinal     disturbances     in, 
629. 
creosote  in,  630. 
hemorrhage,  631. 

constricting  rubber  bands  in,  63-4. 
ice  bag  in,  634. 
morphin  in,  632. 

treatment  of,  from  empyric  stand- 
point, 633. 
adrenalin  in,  633. 
suprarenal  extract  in,  633. 
from     physiologic     standpoint, 
633. 
nitrites  in,  633,  634. 
nitroglycerin  in,  634. 
salts  in,  634. 
from  scientific  standpoint,  633. 
hypophosphites  in,  621. 
iron  in,  621. 

loss  of  appetite  and  weight  in,  619. 
cod-liver  oil  in,  620. 
liquid  food  in,  620. 
olive  oil  in,  620. 
night  sweats  in,  628. 
strychnin  in,  621. 
Trudeau,  N.  Y.,  701. 
Tubercle,  caseation  in,  55. 
caseation  of,  56. 
epithelial  cells  of,  52. 
exudative  inflanmiation  caused  by,  56. 
gathering  of  leucocytes  about,  54. 
giant  cells  of,  significance  of,  54. 
simulated  by  hyaline  thrombi,  54. 


Tubercle,  typical,  53. 

granulation  tissue  result  of,  55. 
histogenesis  and  fate  of,  52-60. 
in  fibrinous  exudates,  53. 

showing    development     from     emi- 
grated leucocytes,  53. 
showing   development   from   young 
connective-tissue  cells,  53. 
in  parenchymatous  organs,  53. 
mitotic  figures  in  formation  of,  53. 
multinuclear  giant  cells  frequent  in,  53. 
nonformation  of  new  vessels  in,  55. 
obliteration  of  preexisting  vessels  on 

site  of,  55. 
origin  of,  52-55. 
reticuhun  in,  55. 
serous  exudation  in,  55. 
starting  point  of,  52. 
Tubercle  bacilli,  attenuated,  566. 

loss  of,  in  tuberculin  treatment,  564. 
mobilization  of,  in  repeated  doses  of 

tuberculin,  553. 
young,  loss  of  stain  in,  17. 
Tubercle  bacillus,  16,  17,  20,  29,  42,  56, 
62,  79,  186,  222,  223,  228,  249, 
257,    301,    325,    418,    423,    424, 
449,    458,    476,    477,    499,    501, 
570,    578,    611,    640,    648,    678, 
726,    751,    808,    810,    816,    855, 
924,    947,    989,    995,    996,    1044, 
1046,  1052,  1076. 
Tubercle  bacillus  in  milk,  414,  415. 
Tubercle     bacillus,    absence     of,     toxic 
formation  in,  29. 
acid-fast    bacilli    differentiated    from, 

18,  20. 
action  of  gastric  juice  on,  38. 
activity  of,  in  dried  sputum,  24. 
analysis  of,  26. 
analysis  of  ash  of,  27. 

from  various  sources,  27. 
biology  of,  23-25. 
bovine,  danger  in  infection  by,  47. 
occurrence   of,    in    ])ulmonary   con- 
sumption, 49-50. 
transmissibility  of,  to  human  beings, 
49-51. 
carbohydrates  in,  28. 
chemical  composition  of,  26-28. 
chemistry  of,  49. 
composition  of  waxy  substance  of,  28. 


934 


INDEX 


Tubercle  bacillus,  cultivation  of,  20-23. 
cultural  characteristics  of,  48. 
cultures  of,  homogeneous,  22-23. 
human,  Hesse's  method  of  isolation 

of,  22. 
isolation  of,  21. 

method  of  Theobald  Smith  in,  21. 
on  hen's  egg,  Dorset's  method  of, 
21-22. 
obtaining  of,  21. 

use  of  acid  potassium  phosphate  in, 
22. 
decomposition  of,  24-25. 
destruction  of,  by  sunlight,  24. 
differentiation  of,  from  pseudo-tubercle 

bacillus,  18. 
diffused  light  on,  action  of,  40. 
discovery  of,  by  Koch,  13. 
disinfection  of  sputum  containing,  25- 
dissemination  of.     See  Dissemination, 
dried,  chamber  for  handling,  49. 
effect  of  burial  on,  25. 
of  chemicals  on,  25. 
of  darkness  and  moisture  on,  25. 
exudative    inflammation    caused    by, 
56. 
process  of,  55. 
fat  in,  amount  of,  27,  28. 
composition  of,  27,  28. 
forms  of,  which  are  not  acid-fast,  17. 
history  of,  13. 

in  cold-blooded  animals,  14. 
in  sputum,  Herman's  method  of  stain- 
ing, 17. 
in  sputum  deposited  in  puljlic  places, 
32. 
effect  of  darkness  and  moisture  on, 
32. 
in  sputum  deposited  in  street,  32. 

effect  of  light  and  air  on,  32. 
inorganic  constituents  of,  26. 
isolation  of,  various  media  used  in,  21. 
invasion   of   lungs   by,   from   food   in 

digestive  tract,  63. 
invasion  of  lymph  nodes  by,  79. 
invasion  of  walls  of  blood-vessels  by, 

64. 
latency  of,  in  lymph  nodes  of  children, 

60. 
lepra  bacillus  differentiated  from,  by 
staining,  18-19. 


Tubercle     bacillus,     localization    of,    in 
lymph  nodes  during  childhood 
possible  cause  of  pulmonary  tu- 
berculosis, 62. 
method  of  growing,  for  tuberculin,  22. 
modes  of  invasion  of,  33.       See  also 

Modes  of  Invasion, 
morphology  of,  15. 
shape  of,  15. 
size  of,  15. 
staining  of,  15. 
occurrence  of,  31. 

outside  of  body,  23. 
organic  constituents  of,  26. 
points  of  entrance  of,  60. 

by  direct  implantation  on  skin  and 

mucous,  60. 
by  inhalation  of  bacilli  in  dust  or 

droplets  of  sputum,  60. 
by  intra-uterine  infection,  60. 

latency  of  bacilli  in  lymph  nodes  of 
children  in,  60. 
by  introduction  into  digestive  tract 
in  food,  60. 
primary  infection  in,  60. 
poisons  of,  28-30. 
primary  localization  of,  60. 
at  point  of  entry,  60. 
in  digestive  tract,  62. 
in  lungs,  61. 
in  lymph  nodes,  60. 

most  frequent  in  children,  61. 
of  adult,  61-62. 
percentage  of,  in  various  organs,  61- 
predisposition  of  apical  parts  of  lung 
to,  62. 
proteids  in,  28. 

products  of,  in  treatment  of  tubercu- 
losis, 567. 
pseudo-tubercle  bacillus  differentiated 

from,  by  staining,  18. 
relation  between  human  and  bovine, 

46. 
relative    frequency    of    primary    and 
secondary    localization    of,    in 
pulmonary  tuberculosis,  62. 
resistance  of,  to  destructive  agents,  24. 

to  home  pasteurization,  24. 
smegma  bacillus  differentiated  from, 

by  staining,  19. 
sources  of  infection  of,  31. 


INDEX 


935 


Tubercle  bacillus,  source  of  infection  of, 
from  bovine  tuberculosis,  32. 
from  sputum,  32. 

by  handkerchiefs,  32. 

by  hands,  32. 

by  kissing,  32. 

distribution  of,  32. 

distribution    and    suspension    of, 

32. 
dry  and  pulverized,  32. 
in  droplets  from  mouth,  32. 
in  public  places,  32. 
in  streets,  32. 
spore  formation  in,  24. 
stages  of  development  of,  17. 
staining  of.     See  also  Staining, 
differential,  19. 

Bunge  and  Trantenroth   method 

of,  19. 
Sudan  III  method  of,  11). 
temperature  necessary  for  cultivation 

of,  23. 
types  of,  13,  46. 
of  birds,  14. 
of  mammals,  14. 
viabihty  of,  46. 

von  Behring's  three  hypotheses  of  in- 
gestion of,  in  early  life,  87. 
TubercuHn,    67,    73,    92,    108,    135,    145, 
178,    208,    231,    234,    235,    243, 
282,    292,    296,    304,    342,    355, 
375,    376,    377,    386,    387,    392, 
399,    412,    417,    422,    429,    431, 
432,    436,    437,    438,    463,    471, 
476,    477,    479,    503,    567,    568, 
569,    571,    574,    579.    581,    585, 
586,    587,    588,    608,    622,    623, 
627,    643,    651,    658,    660,    673, 
674.    675,    702,    706,    707.    725, 
749,    754,    765,    768,    772,    815, 
818,    824,    831,    832,    837,    842, 
845,    859.    868,    877,    878,    886, 
932,    958,    964,    965,    977,    979, 
980,  981,  988,  1030,  1045,  1066, 
1074. 
Tuberculin  in  treatment  of  tuberculosis, 
508.       See      also     Tuberculin 
Treatment, 
antipyretic  action  of,  534. 
chemistry  of,  517. 
dilutions  of,  520. 


Tuberculin  in  treatment  of  tuberculosis, 
dilutions  of,  diluents  used  in, 
521. 
estimating  of,  521. 
method  of  making,  520. 
preservation  of,  520. 
tlose  of,  524. 
beginning,  524. 
final,  535. 

hypersuscei^tibility  to,  538. 
in  general,  524. 
increase  of,  525. 

by  clinical  method,  526. 
by  laboratory  method,  526. 
estimation   of  patient's  condition  in, 

535. 
general  symptoms  of,  532. 
interval  between  doses  of,  525. 
local  sym{)toms  of,  531. 
methods  of  administration  of,  518. 
dermic,  519. 
inhalation,  519. 
intravenous,  518. 
oral,  518. 

subcutaneous,  519. 
organ  reactions  to,  531. 
preparation  for  injections  of,  523. 
accidental  inoculation  in,  523. 
cleansing  of  needles  in,  523. 
cleansing  of  skin  in,  523. 
site  of  inoculation  in,  523. 
prophylactic  use  of,  545. 
pulse  in,  534. 
repeated  doses  of,  551. 
blood  in,  551. 

blood-pressure,  552. 
erythrocytes,  551. 
leucocytes,  551. 
.serum,  552. 
untoward  results,  552. 
complications  in,  555. 
effects  of,  551. 

elevated  temperature  in,  554. 
experimental  results  in,  556. 
hemoptysis  in,  555. 
mobilization   of  tubercle  bacilli   in, 

553. 
jiathologic  changes  in,  555. 
physical  signs  in,  555. 
sputum  in,  553. 
urine  in,  554. 


936 


INDEX 


Tuberculin  in  treatment  of  tuberculosis, 
repeated  doses  of,  weight  in,  551. 
selection  of,  545. 
skin  reaction  of,  530. 
time  of  injection  of,  527. 
tyi)ical  reaction  of,  529. 
Tuberculin,  method  of  growing  tubercle 
bacilli  for,  22. 
Old,  515. 

preparation  of,  30. 
Beraneck's,  31. 
Klebs's  antiphthisin,  30. 
Klebs's  tuberculocidin,  30. 
Koch's,  new  varieties,  31. 

B.  E.  (Bacillen  Emulsion),  31. 
T.  A.  (Tuberculin  Alkaline),  31. 
T.  O.  (Tuberculin  Oberst),  31. 
T.  R.  (Tuberculin  Rest),  31. 
Maragliano's,  30. 
of  State  Live  Stock  Sanitary  Board 

of  Pennsylvania,  30. 
original,  of  Koch,  30. 
Spengler's  (Perlsucht),  31. 
tuberculol,  31. 
von  Behring's,  31. 
tuberculase,  31. 
tulase,  31. 
tulaselactin,  31. 
von  Ruck's,  30. 
treatment    during    administration    of, 
550. 
medicinal,  550. 
rest  and  exercise  in,  550. 
rise  of  temperature  in,  550. 
sanatorium,  550. 
vaccines  in,  550. 
varieties  of,  used  clinically,  515. 
antiphthisin,  516. 
Bacillen  Emulsion  (B.  E.),  516. 
Beraneck's  Tuberculin,  516. 
Broth  Filtrate  (B.  F.),  516. 
Old  Tuberculin,  515. 
Tuberculin  R.,  516. 
Tuberculocidin  (T.  C),  516. 
"Watery  Extract,"  516. 
Tuberculin  R.,  31,  515,  516. 
Tuberculin  test,  339,  549.   See  also  under 
Diagnosis, 
contraindications  for,  346. 
dosage  in,  342. 
modifications  of,  346. 


Tuberculin  tests,  11,  38,  192,  238,  259, 
287,  288,  386,  473,  491,  623, 
642,  674,  714,  715,  718,  740, 
776,  779,  780,  781,  782,  783, 
850,  851,  857,  863,  897,  904, 
907,  925,  926,  935,  985,  1017, 
1035,  1067,  1068,  1069,  1070, 
1080,  1081. 
Tuberculin  treatment,  advice  to  patient 
inquiring  about,  545. 
complications  of,  535. 

age  in,  535. 
duration  of,  548. 

repeated  courses  in,  549. 
tuberculin  test  in,  549. 
record  of,  527. 
results  of,  556-565. 

reports  of,  560-564. 
selection  of  patients  for,  541. 
age  in,  545. 
complications  in,  544. 
duration  of  disease  in,  545. 
elevated  temperatures  in,  543. 
physical  signs  in,  544. 
symptoms  and  general  condition  in, 

543. 
theory  of  action  in,  541. 
small  doses  in,  schemata  of,  539. 

value  of,  538. 
susceptibility  in,  increased,  534. 
temperature  in,  532. 
weight  in,  534. 
Tuberculocidin  (T.  C),  516. 
Tuberculosis,  60,  71,  72,  84,  120,  142,  143, 
159,    162,    195,    196,    213,    227, 
336,    440,    580,    582,    595,    596, 
601,    613,    620,    626,    672,    677, 
681,    698,.  710,    716,    717,    727, 
733,    736,    737,    739,    757,    758, 
778,    790,    850,    851,    873,    976, 
1007,  1062,  1077. 
Tuberculosis  exhibition,  260,  272. 
Tuberculosis,  first  stages  of,  66,  450,  835, 

890,   915,   1061. 
Tuberculosis,  varieties  of,  444,  1007. 
"Tuberculosis     a     children's     disease," 

112. 
Tuberculosis,  a  potent  cause  of  mental 
degeneracy,  101. 
acute,  of  serous  membranes,  cause  of, 
64. 


INDEX 


937 


Tuberculosis,  acute  miliary,  64. 
cause  of,  64. 

secondary  infectious  disease,  64. 
among     the     dark-skinned     races     of 
America,  118-130. 
general  consideration  of,  118-120. 
in  Indian,  127-129. 
in  Japanese  and  Chinese,  12'.)-l;>0. 
in  mulattoes,  12.3. 
in  negro,  121-127. 
bovine,  relation  of,  to  human  health, 
32,  35,  44. 
transmissibility  of,  49-51. 
clinic  for,  433-438. 
object  of,  434. 
plan  of,  435-436. 
Committee  of  the  C.  O.  S.,  New  York 

in,  442. 
diagnosis  of,  by  microscopic  examina- 
tion, 20. 
dusty  occupations  a  cause  of,  101. 
exhibits  of  preventive  devices  of  in, 

425-433. 
frequency  of,  105-117. 

in  regard    to    geographic   location, 
116-117. 
geographic  distribution  of,  116-117. 
hereditary,  33. 

immunity    to,    93-96,    118-120.     See 
also  Immunity, 
specific  substances  in  blood  in,  96. 
in  children.     See  under  Children, 
in  Indian.     See  under  Indian, 
in  insane,  131-138. 
diagnosis  of,  134. 
in  asylums,  mortality  in,  132. 

statistics  of,  131. 
in  hospitals,  133. 

difference  of  prevalence  in  the  two 

sexes,  134. 
employment  for,  134. 
etiology,  of,  133. 
inactivity,  133. 
overcrowding,  133. 
uncleanliness,  133. 
treatment  of,  135. 
individual,  135. 
by  camp  life,  137. 
in  sanatoria,  135. 

of    those    who    refuse   food, 
137. 


Tuberculosis,    in    insane,    treatment    of 
preventive,  135. 
examination  upon  entrance  in, 

135. 
exercise  in,  135. 
hygienic  methods  in,  135. 
in  Japanese  and  Chinese,  129-130. 

etiology  of,  129. 
in  negro,  121-127. 
causes  of,  121-122. 
compared     with     tuberculosis     in 

Indian,  123. 
mortahty  in,  123. 
statistics  of,  124-127. 
insurance  against,  493. 
intertransmissibility  of,  47. 
intestinal,  38,  756.     See  also  Intestinal 
Tuberculosis, 
experiments  in,  40-44. 
frequency  of,  49-51. 
primary,  38. 

primary  intestinal  ulcers  in,  61. 
statistics  of,  38-40. 
lymphatic,  88. 

miliary,  character  of  tubercles  in,  67- 
68. 
entrance  of  infection  into  blood  in, 

65. 
general,  nature  of,  65. 
point  of  origin  of,  66. 
tuberculosis   of   thoracic    duct   a 
cause  of,  66. 
localization  of  tubercles  in,  67. 
of  pia-arachnoid,  68. 
organs  involved  in,  67-68. 
tuberculous  lesion  of  blood-vessels  a 
source  of,  conditions  necessary, 
65. 
variation  in  number  of  tubercles  in, 
67. 
mixed  and  concomitant  infections  in, 

589-599. 
morbid  anatomy  of,  52. 
mortality  statistics  in,  compared  with 

those  of  pneumonia,  116. 
of  bladder,  791.     See  also  Bladder, 
of  bones,  731.     See  also  Bones, 
of  brain,  754. 

tuberculomas  in,  754. 
of  digestive  tract,  swallowing  of  tuber- 
culous sputum  a  cause  of,  64. 


938 


INDEX 


Tuberculosis  of  fasciae,  7.50. 

of  genital  tract  in  women,  794.     See 

also  Genital  Tract, 
of  genito-urinary  system,  777. 
of  joints,  735.     See  also  under  Joints 

and  individual  joints, 
of  kidney,  785.      See  Renal  Tubercu- 
losis, 
of  lymph  glands,  723.     See  also  under 

Lymph  Glands, 
of  meninges,  751. 
diagnosis  of,  751. 
symptoms  of,  751. 
treatment  of,  752. 
surgical,  753. 
of  muscles,  750. 

of  peritoneum,  771.     See  also  Perito- 
neal Tuberculosis, 
of  seminal  vesicles  and  prostate,  784. 
of    shoulder  -  joint,    742.         See   also 

Shoulder-Joint, 
of  spinal  cord,  755. 
of  suprarenal  gland,  791. 
of  synovial  membrane,  736. 

arthrectomy  in,  742. 
of  testicles,  779.     See  also  Testicles, 
of  urethra,  774.     See  also  Urethra, 
of  walls  of  blood-vessels,  66. 
character  of  tubercles  of,  67. 
mode  of  origin  of,  66. 
point  of  origin  of,  66. 
peritoneal,  origin  of,  64. 
predisposition  to,  82.     See  Predispo- 
sition, 
primary  local,  a  source  of  secondary 

tuberculosis,  62. 
progressive  local,  marked  by  tubercles 

in  lymph  channels,  63. 
prophylaxis  of,  391. 
individual,  393. 
public  measures  in,  410. 
public  press  and,  424. 
pulmonary,    acute    general    hemafog 
enous,  70. 
morbid  anatomy  of  lungs  in,  70. 
fibroid,  78. 
latent,  88. 
localized,  71. 

lobar  pneumonia  in,  73. 
process  of  evolution  of,  71-72, 
mixed  infection  in,  77. 


Tuberculosis,  pulmonary,  morbid  anat- 
omy of,  69-77. 
variety  of  anatomic  alterations  in, 
69. 
partial  disseminated  hematogenous, 

70. 
pneumonia  in,  72. 
previous,   a  danger  for  reinfection, 

88. 
primary,     predisposing     factor     to 

secondary  autoinfection,  88. 
quiescent  or  healed,  78-79. 
ulcerative,  74. 
resistance  to,  80-93. 

in  animals  in  general,  80. 
in  man,  80. 
increased,  91,  93. 
individual,  80.    • 
normal  physiologic,  81. 
subnormal,  82. 
secondary,    seat    of,  in    lymph  nodes 
draining    tuberculous    regions, 
63. 
specific  treatment  of,   508.     See  also 

Specific  Treatment, 
statistics     from     autopsies     on,     by 

Nageli,  106. 
strain,  physical  and  mental,  a  cause  of, 

101. 
surgical,  723. 

surgical    forms    of,    susceptibility    of 
cattle  to,  47. 
experiments  in,  47-48. 
susceptibility  to,  nonspecific,  89-91. 
specific,  from  previous  tuberculous 
infection,  87-88. 
treatment  of,  ''false  specifics"  in,  575- 
585. 
introductory,  505-507. 
specific,  508. 

tuberculin,  508.  See  also  Tuberculin, 
worry  a  cause  of,  101. 
Tuberculous,  soul  of,  400. 
Tuberculous  bronchopneumonia,  72. 
chronic,  73. 
in  children,  72. 
morbid  anatomy  of,  72-73. 
Tuberculous  exudates,  caseation  of,  58. 
Tuberculous  exudative  inflammation,  56. 

process  of,  55. 
Tuberculous  gra,riulation  tissue,  55. 


INDEX 


931) 


Tuberculous   inflammation,    diffuse   and 
acute,  cause  of,  64. 

Tuberculous  lobar  pneumonia,  73. 

Tuberculous  milk,  protection  against  in- 
fection by,  474. 

Tuberculous  peritonitis,  187. 

Tuberculous  pneumonia,  72. 
acute,  cause  of,  64. 

Tuberculous  sputum,   dissemination   of, 
from  handkerchiefs,  32. 
from  hands,  32. 
suspension  in  air  of  droplets  of,  32. 

Tuberculous   tissue,    transformation   of, 
into  fibrous  tissue,  o'J. 

Tumor  albus,  737,  738. 

Tympany,  243. 

Ulcerative  pulmonary  tuberculosis,  74. 

bronchiectasis  in,  75. 

bronchopneumonia  in,  75. 

cavities  in,  75. 

hemorrhage  in,  76. 
Urethra,  tuberculosis  of,  794. 
Urine  in  renal  tuberculosis,  787. 
Urine  in  repeated  doses  of  tuberculin, 
554. 

Vaccination,  186,  367,  403,  410,  411,  413, 

652,  653,  842,  862,  897,  994. 
Vaccination  by  digestive  tract,  180,  182, 
Vaccination  in  tuberculosis,  567. 


Vaccines,  8,  76,  104,  164,  169,  430,  728, 
792,  827,  862,  943,   1033,   1076. 

Venous  terminals  in  bones,  tuberculosis 
of,  732. 

Vertebrse,  tuberculosis  of,  734. 

Vital  reactions  in  high  altitudes,  676. 

von  Pirquet's  phenomenon  in  diagnosis, 
738. 

Walking  in  tuberculosis,  613. 

"Watery  extract,"  516. 

Weigert,  65,  66. 

Weight  gain  by  food,  602. 

Weight  in  repeated  doses  of  tuberculin, 

551. 
Weight  in  tuberculosis,  133,  173,  236. 
\\'indow  tent,  544,  562. 
Window  tent,  Knopf,  482. 
Wright's  demonstration  of  opsonic  index, 

739. 

X-ray  diagnosis,  428,  566,  572,  589,  590, 

597,  771,  840,  1016. 
X-ray  diagnosis,  386. 
X-ray  examination,  268.     See  also  under 
Objective  Signs, 
in  tuberculosis,  304,  320. 
of  tuberculous  joints,  740,  741. 
X-ray  treatment,  750. 

Yeast  in  tuberculosis,  566. 


(1) 


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DATE  DUE 


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